More on the new cancer screening recommendations

Dr. Robert Truog weighs in on the controversy in The New England Journal of Medicine:

Screening mammography for women in their 40s is clearly effective. The problem is that the benefit is tiny and expensive. A recent cost–benefit analysis showed that adherence to the current guidelines from the American Cancer Society costs more than $680,000 per quality-adjusted life-year (QALY) gained, as compared with a proposed alternative costing only $35,000 per QALY. Statistician Donald Berry has calculated that for a woman in her 40s, a decade’s worth of mammograms would increase her lifespan by an average of 5 days — and this survival advantage would be lost if she rode a bicycle for 15 hours without a helmet (or 50 hours with a helmet). The key issue here, however, is that these figures represent population averages. For the small number of women whose lives are saved, the difference is literally as large as that between life and death.

Unfortunately, this debate could not come at a worse time for the Obama administration and advocates of health care reform, since it highlights a necessity that most Americans want to deny. Yet critics of the Task Force recommendations and of health care reform in general are offering a false choice. The choice is not between health care rationing and some undefined alternative, since there is no alternative. Rather, the choice concerns what principles we will use to ration health care. In the United States, we have traditionally rationed health care in the same way we ration expensive cars: those who can afford to pay for them are those who can have them. The alternative currently being considered in health care reform would involve a shift to other principles, such as those rooted in considerations of fairness, efficiency, and efficacy.

Dr. Truog also contrasts mammograms with PSA screening for prostate cancer in men:

It is interesting to compare these proposed guidelines with those that have been suggested for the prostate-specific antigen (PSA) test, another screening method for another cancer. In the case of PSA testing, a credible argument can be made that the test is often harmful for the individual patient. False positive results often lead to biopsies (which are themselves often unreliable) and then to invasive procedures such as surgery and radiotherapy that can leave patients impotent or incontinent, often to treat a prostate condition that never would have threatened their life. Mammography is different. Although abnormalities found on mammography generally necessitate additional imaging or a biopsy, the risks associated with these procedures are relatively limited.