| I was
stunned when I read the recent announcement from U.S.
Preventive Services Task Force (USPSTF) stating that
they would no longer recommend routine screening
mammography for women under the age of 50 years, no
longer recommend that doctors teach Breast
Self-Examination (BSE), and no longer recommend yearly
clinical breast examinations.
The
panel seems to be suggesting that women in this age
group simply wait until a tumor grows to the point where
it becomes so obvious that it will likely be incurable.
This is a major step backward.
It is well known that studies from
Sweden
demonstrate a 40% mortality reduction in association
with yearly mammography screening in the 40-50 year age
group.
The
task force actually admits that screening mammography
saves lives in young women, but concludes that there is
insufficient data to justify the emotional distress and
costs associated with screening.
They point out that screening leads to a large
number of negative biopsies which are costly and of no
medical benefit.
The
American Cancer Society (ACS) has a panel of experts who
also reviewed the literature.
The ACS concludes that screening mammography is
appropriate in the 40-50 year age group.
Both panels indicate they propose guidelines that
are designed to insure best value, which is defined as
achieving the best medical outcome at the lowest cost.
To achieve best value, the panel from the ACS put
more weight on the issue of outcome, and the panel from
USPSTF put more weight on the issue of cost.
Such differences in interpretation are
predictable in a system of care in which third parties
rather than individuals pay for services.
The
reason a government panel would emphasize
cost-containment is readily understandable. Costs of
medical care are spiraling out of control.
The government will be unable to meet its
objective of providing universal access to reasonably
priced medical care unless the costs of care are brought
under control.
The
panel does make one important point on the issue of
cost-containment. They correctly state that there is no
published data that demonstrates a survival advantage
for screening women over 74 years of age. There are
undoubtedly some women in this age group who would
benefit from screening.
Physicians should share this information with
their patients to assist them in making informed
decisions.
The
behavior of breast cancers in younger women is much
different than it is for seniors. Many of the cancers
that develop in women over 74 years of age are slow
growing and if left untreated would not influence
survival. Cancers in young women tend to be aggressive.
If left untreated or diagnosed late, these cancers will
kill.
Early
mammographic detection of breast cancers in the under-50
age group is complicated by the fact that these women
tend to have dense breasts making early detection more
challenging. Also, younger women are more likely to have
rapidly growing cancers that are either not detected on
mammograms or show up as new lumps between yearly
mammograms. However,
despite a multitude of challenges, numerous studies from
both the
U.S.A.
and abroad demonstrate the life-saving value of
screening in the 40-50 year age group.
There
are also other early detection strategies that provide
additional layers of protection.
Women who do BSE with confidence are often able
to perceive small and potentially curable cancers that
are not detected on mammograms.
Physicians, who inspire women to perform proper
BSE and support them when they do detect subtle changes
on self-exam, add an additional layer of protection.
In the
bigger picture, the guidelines as proposed may offer a
glimpse into what is in store for the public as the
government attempts to achieve budget neutrality while
providing universal access to care. Their recommendation
to restrict life-saving care to young women is an
indicator of how far government panels may be willing to
go to achieve their cost-containment objectives.
Fortunately, the new guidelines have for the most
part been rejected, but pressures for cost-containment
will continue to mount and other approaches to rationing
of care will be advanced.
The alternative to rationing is to restructure
the healthcare system to improve efficiencies, eliminate
marginally beneficial procedures, and provide incentives
for physicians to compete for best value of services. It
will take an informed and energized public to insure
that the focus of our evolving health care system is on
creating value rather than controlling costs.
John
G. West, MD
Co
Founder: Be Aware Foundation
www.beawarefoundation.org
Surgical
Director
Breast
Care & Imaging
Center
of
Orange
County
www.breastcare.com
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