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As we watch the reform movement in Washington, we see and hear so many misconceptions. A current one relates to mammography. A few weeks ago guidelines were published in the prestigious Annals of Internal Medicine stating, in effect, that women between ages 50 and 75 with no history of breast cancer in their family and normal mammograms to date could probably switch from annual to biannual exams. And women between ages 40 and 50 probably did not need to get mammograms as had been previously recommended unless they had certain high risk circumstances. These recommendations were made by an expert, non-partisan panel with no apparent conflicts of interest in the guidelines. The recommendations were made based on careful examination of all of the relevant data on the benefits and risks of mammography to detect early breast cancer. With a lifetime risk of breast cancer being about 9%, women need unbiased advice on what to do to detect cancer early when it is most curable. But they also need advice on when a testis not needed or can lead to unnecessary biopsies, anxieties and expense.
These newly released guidelines from the Preventive Services Task Force ignited some firestorms. The first was from various advocacy groups who have worked for years to assure that women could access mammographic screening programs annually and have the procedure paid for by insurance. Women have begun to understand the importance of routine screening and often set their exam dates by their birthday other annual event. This relatively easy approach to remembering to get a needed test has been useful but might be lost with biannual exams and this worries many advocacy groups. Second, many women chimed in saying that they developed breast cancer at a young age and it was only for the mammogram that it was found at an early stage and hence was cured. A third group, the many providers along with the manufacturers of mammographic equipment, see that reducing the frequency of mammograms will substantially impact their businesses and profits. Some smaller breast evaluation centers might go out of business altogether if procedures drop by 50% as would happen if the guidelines were fully followed. None of these groups want new guidelines that will encourage fewer women from having routine mammograms at the same schedule as formerly advised. But that was only part of the problem with the new guideline recommendations.
Those who want to defeat the current healthcare reform proposal in Congress are using these new guidelines as their "proof" that reform will mean rationing. To them, it represents the “heavy hand” of government making decisions rather than the patient or her physician. This is an excellent approach to raise high levels of concern especially in a population of individuals that tend to vote and tend to contact their elected representatives in Congress. In fact the Task Force did not suggest that insurance standards be changed although one could surmise that insurers might decide to limit reimbursement if the accepted guidelines so suggested. And so the secretary of Health and Human Services felt compelled to state that this would not impact insurance and Senator Barbara Mikulski of Maryland offered the first proposed amendment to the Senate health reform bill to prevent just such a possibility.
These firestorms erupted rapidly when in fact the new guidelines are just a reasonable attempt by a group of nonpartisan experts to offer women and their physicians the best current evidence as to what is most efficacious and least risky so that they, and they alone, can make rational decisions about care.
Truth is that medicine needs more and more efforts to assure that the care of patients is based on solid evidence. All too much of medical care is based on what we learned in medical school years ago, what we read about recently or what our personal experiences have been. This must change and guidelines from well respected unbiased experts can make a big difference in improving the quality of care.
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Praise for Dr Schimpff
The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.
-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).
1 comment:
Very nice discussion of the mammogram issue. Perhaps one of the lessons of this debate was the disconnect between the very rationale approach of the guideline panel, and the utter failure of the media to engage in a rationale informed discussion.
It seems the fear of cancer makes it hard to have a serious discussion of the significant risks of screening. In fact, many patients who go through all the complications of a false positive test may believe they were helped by the screening. There is an interesting post on Geripal.org that discusses this issue. (http://www.geripal.org/2009/12/overwhelming-relief.html)
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