Posts Tagged ‘mammography’

A large mammography screening study from Sweden made the news.  The study assessed whether regular mammography saves lives in women ages 40-49.  The study compared women in counties that offered routine screening to women in counties that didn’t.  There was a higher death rate among women in the counties that did not offer regular mammography.

If the death rate is lower when regular mammography is offered, shouldn’t all women in the 40-49 age group get regular screening mammography? Well, it may not be that simple.  First, while the death rate without regular mammography was higher by about 30 percent, the death rate was still rather low, with 11 deaths per 10,000 women with screening, and 14 deaths per 10,000 women without screening.  For the three people in 10,000 who die needlessly, this is huge.  For the other 9,997 women out of 10,000, the additional screening doesn’t save a life.  And there is the possibility that many of those women will suffer needlessly from false positive results.

Whether or not screening mammography should be done in women in the 40-49 age group without risk factors seems to be a decision those women should make in consultation with their doctors.  To hear more about it, listen to the Getting Better Health Care show we did on this topic.

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The U.S. Preventive Services Task Force (USPSTF) — a quasi-governmental, independent panel of experts in primary care and prevention charged with systematically reviewing the evidence of effectiveness and developing recommendations for preventive health services — just created a whole lot of hoopla by changing their mammography screening recommendations. They made the changes in an environment politically charged by the ongoing health care reform debate and raised the ire of some patient advocates.

The USPSTF is a trustworthy, conservative body that focuses on evidence, not politics. However, the decisions the USPSTF makes, certainly in this case, can have massive political implications. As a researcher who once studied the health screening and prevention needs of patients, I used the venerated guidelines set by the USPSTF as the criterion for assessing these needs. As a dermatologist, I’m familiar with USPSTF recommendations largely because of what they DON’T recommend: skin cancer screening.

Among dermatologists — doctors who see skin cancer every day — there is widespread support for skin cancer screening. The USPSTF, which focuses on scientific evidence, sees no proven net benefit and does not recommend routine skin cancer screening, much to the chagrin of most dermatologists. However, I trust their judgment. The USPSTF doesn’t support politically expedient skin cancer screening, because the evidence to support routine skin cancer screening is lacking.

The USPSTF has my trust, but many others don’t share that view. Listening to the debate over the change in mammography screening recommendations, I hear emotional and quasi-scientific rants about the horrors of the new mammography recommendation and how the lives of women are being totally discounted by the Task Force. I’m sure the Task Force carefully considered those lives. The specific evidence for how many lives are saved by routine mammography screening for women in the 40-50 year age range is roughly one life saved for every 2,000 women screened. And I am sure the USPSTF weighed that benefit against the risks of screening. What are those risks of screening? There are false positive tests that can result in morbidity and scarring from the resulting biopsies, as well as a profound emotional toll brought on by being told, “you have an abnormal mammogram.”

Those who view the changed USPSTF mammography screening recommendation through the lens of the health care reform debate magnify the noise surrounding the scientific controversy with allegations that a quasi-governmental body is deciding the future of women’s health and making recommendations to ration care away from women while callously ignoring the lives of our mothers, sisters and daughters who will die needlessly. They say this proves that the last thing we need now is more government involvement in American health care. I’m not so paranoid.

The Task Force didn’t ignore women’s lives. On the contrary, it carefully weighed the risks and benefits to women. The Task Force didn’t ration care. On the contrary, while the Task Force didn’t recommend routine mammography for women in their 40s, the Task Force did recommend that the decision to have mammography “should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms.”

And that, to my ear, is a good thing. Patients should be empowered to make individual decisions based on the best evidence and on their own unique situations and preferences. The concept of patient-centered care and greater involvement of patients in their own health care underlies both the USPSTF recommendations and everything that I have advocated about patient satisfaction and feedback through DrScore.com.

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