The fallout from the mammogram screening guidelines have served as a test case, of sorts, to see how the politicians and public will respond to recommendations based on evidence-based clinical practice.
And, judging from the inflammatory reaction, it’s safe to say that we’re quite a ways from medical decisions based on the best available data.
In a recent editorial, the New York Times touched upon the issue. One of the Senate’s health care bill amendments explicitly mentioned the USPSTF and “directed the government to ignore the task force’s most recent mammography recommendations.”
It overwhelmingly passed.
Health reformers are hoping that results from comparative effectiveness trials can help reduce the amount of practice variation, which is a leading driver of rising health spending.
But whenever the evidence calls for less medicine, the political and public outcry will be deafening. Today it’s mammograms. What if tomorrow an independent body calls for, say, a reduction of angioplasty or cardiac bypass surgery, which studies have suggested are being overused?
Both the politicians and the public will simply cry, “Rationing!” Thus, the myth that more care is better care will continue to be perpetuated, and the data ignored.
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{ 11 comments }
Physician, heal thy own clogged ears.
The panel recommendations were a public relations debacle, to be sure, but that panel’s findings were set, in legislation currently pending before congress, to affect reimbursement.
If there was ever a time for skepticism and appraisal, it was in this instance.
And the panel guidelines did rely on modeling which gave widely variable results, on research that diluted mortality benefit, ignored significant live population data from Sweden, had a perfectly arbitrary cut-off point, dealt with no other benefit than mortality benefit, and justified the significant cost in lives with the great benefit of women being spared “worry,” instead of serious harm, and minor procedures, despite the stage set for change in the management of suspicious mammography findings. (elastography, new protocols for management of benign appearing tumors).
With all due respect, I’d like to alert reader to some dissenting view from respected physicians, scientists, and professional organizations who have written up detailed scientific critiques of the USPSTF position.
These are also “data-driven”.
Interested readers can find some at:
“American Cancer Society Responds to Changes to USPSTF Mammography Guidelines”
November 16, 2009
http://www.cancer.org/docroot/MED/content/MED_2_1x_American_Cancer_Society_Responds_to_Changes_to_USPSTF_Mammography_Guidelines.asp
“Why the critics of screening mammography are wrong”
http://www.diagnosticimaging.com/display/article/113619/1493126?verify=0
Daniel Kopans, Diagnostic Imaging, December 4, 2009
(Daniel B. Kopans, M.D., is a professor of radiology at Harvard Medical School and a senior radiologist in the breast imaging division at Massachusetts General Hospital.)
“Frequently Asked Questions about Mammography and the USPSTF Recommendations: A Guide for Practitioners”
http://www.sbi-online.org/associations/8199/files/Detailed_Response_to_USPSTF_Guidelines-12-11-09-Berg.pdf
Wendie Berg, MD, PhD, R. Edward Hendrick, PhD, Daniel Kopans, MD, and Robert Smith, PhD
Society of Breast Imaging, December 11, 2009
(Berg – American Radiology Services, Johns Hopkins Green Spring, Lutherville, MD; Hendrick – Department of Radiology, University of Colorado, Denver, CO;
Kopans – Department of Radiology, Massachusetts General Hospital, Harvard University School of Medicine, Boston, MA; Smith – Cancer Control Sciences Department, American Cancer Society, Atlanta, GA)
Very true, Kevin.
The ‘hue and cry’ results from the unresolvable paradox of the ‘general versus the particular’. Aristotle struggled with this and we must, as well.
It cannot be resolved as long as we operate a first dollar, cost sharing system for medical care. Such a system cannot simultaneously operate on behalf of the individual (the particular) and the insured group (the general).
Be definition, a cost sharing scheme is designed to reduce financial risk for the individual, by spreading unexpectedly large medical expenses amongst the group. When we enter a cost-sharing scheme, we also assume decreased autonomy over our medical choices. Individual autonomy must be subordinated to the group health administration, or there is no cost-sharing…just cost increases. (This is essentially what we have today.)
I’ll echo, once again, the calls of many wise healthcare gurus…We must move toward a high-deductible + health savings model, if we wish to increase individual (patient and clinician) autonomy in healthcare.
More insurance = less autonomy
If the group gets bigger (government healthcare), the individual’s autonomy must diminish. The aporia of the general versus the particular ensures this.
Thanks for the great post!
Ben
“A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it. ” –Max Planck
I say give it time.
I would have felt better about these “data-driven guidelines” had there been at least one oncologist on a task force formulating guidelines for screening for cancer.
Yesterday I received “junk mail” from the medical center of my former doctor, promoting mammography. In the flyer, it stated as someone over 40, I was at risk and how they really cared about my health. It encouraged me to make an appoinment for a mammogram without consulting my doctor. They even promoted a breast exam by a nurse practioner, so conveniently done at the same appointment. The flyer clearly intends to convince the public that the mammogram guidelines should be ignored and I should be scared of breast cancer. There was no statement about discussing my perosnal risk with my doctor or the risks of screening. When does the medical profession take responsibility for fallout from the mammogram recommendations?
The uproar by the public over the new guidelines for mammography, in my opinion, are not because any of us want mammograms every year, but because we have been told for years that we MUST have them annually once we reach 40 and now we are being told that the annual tests will simply “worry” us for no reason. And we know it’s just money. And we know that we cannot trust any “task force” with ANY recommendation. We are disillusioned now, and paranoid, and know that we’ve been misled and will continue to be misled by groups who supposedly have our best interest in mind. What bs!
Interesting use of the word, given that mammograms involve radiation exposure that may by itself slightly increase the risk of breast cancer.
Good example of a badly managed social process. Evidence-based clinical practice will never work because everyone who evaluates the evidence is biased, individual or task force, and there is always more evidence to look at. What eventually becomes traditional is our best guide. We could speed up the evolution of tradition with a wikipedia like web site for physicians and researchers to propose, discuss and vote on standards of practice.
For data driven to work, the math has got to be sound. I looked at some of the articles about mammograms including one that purported to explain the math behind the new recommendations — that article made a big point of something that didn’t actually make sense, mathematically.
Studying the data can be helpful, but only if it’s done correctly. I am skeptical of that right now.
Thank you Mr. Hsieh!
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