Science, or Rationing?

So is this the death panel so many healthcare reform opponents have worried about?  Here’s the actual statement from the panel.  Below are excerpts from The New York Times article:

Most women should start regular breast cancer screening at age 50, not 40, according to new guidelines released Monday by an influential group that provides guidance to doctors, insurance companies and policy makers.

The new recommendations, which do not apply to a small group of women with unusual risk factors for breast cancer, reverse longstanding guidelines and are aimed at reducing harm from overtreatment, the group says. It also says women age 50 to 74 should have mammograms less frequently — every two years, rather than every year. And it said doctors should stop teaching women to examine their breasts on a regular basis.

The task force is an independent panel of experts in prevention and primary care appointed by the federal Department of Health and Human Services.

While many women do not think a screening test can be harmful, medical experts say the risks are real. A test can trigger unnecessary further tests, like biopsies, that can create extreme anxiety. And mammograms can find cancers that grow so slowly that they never would be noticed in a woman’s lifetime, resulting in unnecessary treatment.

Over all, the report says, the modest benefit of mammograms — reducing the breast cancer death rate by 15 percent — must be weighed against the harms. And those harms loom larger for women in their 40s, who are 60 percent more likely to experience them than women 50 and older but are less likely to have breast cancer, skewing the risk-benefit equation. The task force concluded that one cancer death is prevented for every 1,904 women age 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women age 50 to 74, and one death for every 377 women age 60 to 69.

The guidelines are not expected to have an immediate effect on insurance coverage but should make health plans less likely to aggressively prompt women in their 40s to have mammograms and older women to have the test annually.

Congress requires Medicare to pay for annual mammograms. Medicare can change its rules to pay for less frequent tests if federal officials direct it to.

Private insurers are required by law in every state except Utah to pay for mammograms for women in their 40s.

But the new guidelines are expected to alter the grading system for health plans, which are used as a marketing tool.

Researchers worry the new report will be interpreted as a political effort by the Obama administration to save money on health care costs.

Of course, Dr. Berry noted, if the new guidelines are followed, billions of dollars will be saved.

What I find fascinating, especially given the name of this blog, is that the analysis used to make the recommendation appears to be identical in principle to the analysis you would perform if you were counting cards at a blackjack game in Las Vegas, or calculating the value of a financial derivative.  That is, you are trying to balance the risks, the reward and the odds of dying  when doing nothing against the risks, the reward and odds of dying when following the treatment guidelines.  You’re measuring to see if the probability-weighted benefits of treatment outweigh the probability-weighted costs of the treatment when compared to doing nothing.   And I’m not necessarily talking about financial costs.  I’m talking about the cost of radiation exposure, infection from a biopsy, unnecessary surgery, money better spent elsewhere, etc.

Basically, the panel looked at the odds of getting a benefit from the screening for different age groups.  They concluded that the various examinations and diagnostics only prevented one death for every 1904 women screened in the 40-49 age group, which means that 1903 deaths were not prevented by the examinations.  That’s not to say 1903 women died.  It just means that the examinations didn’t help 1903 women because most of them had no cancer in the first place.  For the very few in the 1903 group who did die, the unfortunate truth is that the early mammograms and self-examinations didn’t help.

So you then have to weigh the adverse side effects of those 1903 unhelped women getting radiation exposure from mammograms, which would inevitably lead to a radiologist seeing something on a few of those x-rays, which would lead to biopsies, which sometimes leads to infections or actually finding cancers that would, as the report says, “grow so slowly that they would never would be noticed in a woman’s lifetime, resulting in unnecessary treatment.”  Now you’re exposing the patient to chemo, radiation, and surgery.  All have very serious side effects.

So you balance 1 life saved compared to the mortality rate from the side effects of 1903 women who are not getting any benefit from the mammograms and additional unnecessary treatments.  The panel came to the conclusion that the population as a whole is better off not getting the diagnostic tests.

I don’t know what the answer is, but based on what little I know about the subject, the decision doesn’t seem unreasonable.  But here’s the thing.  In healthcare, numbers and logic don’t matter.  Why?

Remember the statistics: mammograms prevent 1 death per 1904 women in age group 40-49.  So if you eliminate mammograms, you will NOT prevent 1 death per 1904 women.  According to the latest Census data, there are about 22-23 million women in the U.S in that age group.  So do the math.  By not screening 40-49 year olds, there will be nearly 12,000 more cancer deaths per year!


What’s not said in that analysis, however, is that there should be more than 12,000 women saved by not suffering from complications due to unnecessary treatment.  But that is not what good headlines are made of!

So here’s my prediction, with a lot of conditional statements:  If the research that prompted the new guidelines is accurate, and if those guidelines go into effect with the recommendations being adopted by insurance companies who stop paying for mammograms for women between 40 and 49, which, according to this research they should not get because it’s actually better for women in that age category to not get examined, then you will see 12,000 additional preventable deaths each and every year.  It’s not my opinion.  That”s just the numbers.

Here’s my opinion: There is going to be outrage!  Nevermind that the same research says that there will be more than 12,000 women saved by not suffering from the complications of misdiagnosis or unnecessary treatment.  The headlines are going to concentrate on those who died, not those who didn’t.

— uo

Published in: on November 17, 2009 at 12:21 pm  Leave a Comment  

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