Complete with exhaustive footnotes:
Some sort of advisory group recently recommended that women begin mammography screening for breast cancer at age 50, up from the previous recommendation of beginning at age 40. This has generated a fair amount of debate along two lines. The first line of comment is, “I want my mammograms, I don’t care how much it costs, it it saves even one life it’s worth it, and anyway I was diagnosed with breast cancer at age 42.” The second point of controversy is whether this heralds an era of rationed care associated with government controlled health care.
It would be effortlessly clever and irrefutable to point out that if you support government controlled health care reform, get ready for a lot more changes like this as the government seeks to control costs. Any government big enough to give you everything you want is big enough to take away everything you have. But I won’t make that point because anyone who thinks that rationing isn’t part of all (*) health care right now is an ostrich.
The reality is that every procedure costs money, every treatment costs money, every test costs money, every time you touch the health care system it costs money. If this were anything but health care, we would be a bunch of steely-eyes skinflints and demand value for our dollar. Yet because this is health care, we ignore reality to justify what we “want” … an unlimited helping of the best health care that medicine has to offer.
Mammography of women in their 40′s finds 2 cancers per 1,000 women (#) examined. It also finds 98 false positives per 1,000 women examined. A woman is 49 times more likely to be the victim of a false positive than a cancer diagnosis. And 900 of 1,000 are simply negative. So 998 women are subjected to radiation, worry and pain, and cost in order to diagnose the other 2 who have cancer.
Dr. Sanjay Gupta said that 75%-90% of women who are diagnosed with breast cancer have no “risk factors”. The lady (PhD & nurse practitioner) he was interviewing told him that the one good risk factor is age. If Gupta is unable to correlate a risk factor to such a large group of the affected population, then the scientific method (as opposed to TV puffery) would recommend looking for other risk factors because clearly the ones he’s looking at don’t correlate. Fortunately, the lady he was interviewing presented the meaningful risk factor, but Gupta (apparently continuing to practisc issue/advocacy journalism) was unable to make the intellectual shift.
No matter how much we test, there are going to be those who slip through undetected. And in the end, all patients die. There is testing that makes good sense, and there is testing that is based on paranoia and greed (@). The time has arrived for everyone involved, myself included, to understand that providing health care to the population must be based on rational decisions that respect the first half of this paragraph.
(*) Rich people and their families get better health care than you ever will. If you want that kind of health care, you have to be able to write a check for the services you want. If you aren’t writing the check, then whoever is writing the check does and will continue to decide what you get.
(#) Although men get and die from breast cancer, men are not screened at all. http://www.cancer.gov/cancertopics/types/breast The ratio of female to male breast cancer is about the same as the ratio of under-50 women who have breast cancer, yet there is zero advocacy for screening equally at risk men.
(@) Mammography is easy money, losing that business is not going to help anyone’s bottom line. The lady who runs one clinic complained that in the wake of the revised guidance, their business dropped from 25 patients to 17 patients per morning. They won’t meet their profit goals if that continues.