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Revolt of the booboisie

Maclean’s newest blogger Colby Cosh on the hurdles of U.S. health care reform. Take for instance, those mammograms.


 

Speaking of health care reform in the USA… if you need a demonstration of what it’s up against, study the apoplectic response to new guidelines for breast cancer screening issued by the U.S. Preventive Services Task Force, an independent agency of the Department of Health and Human Services. The USPSTF has decided to recommend that women aged 40-49 should no longer bother obtaining mammograms as a matter of course; that women 50 and up need them only once every two years; and that breast self-examination is largely useless. The result has been the creation of an instant coalition of rage between conservatives paranoid about “death panels”—behold, an example of the real thing, already doing its genocidal work!—and conspiracist women paranoid about a male-dominated medical profession and its apparent desire to do away with them. (Some people, of course, manage to be both at the same time.)

Confronted with such a tag team, HHS secretary Kathleen Sebelius couldn’t throw her task force under the proverbial bus fast enough. She promised that the new guidelines “won’t set US policy”. In practice, she has thus established frequent breast cancer screening as a sacred taboo. The evidence on the costs and benefits of intensive screening is still evolving, but the debate is over. Even if other clinical agencies come to agree with the USPSTF, as they might, neither Medicare nor future Obamacare will be politically able to budge from the orthodoxy of routine annual screening for every woman over 40.

The key word here is “routine”. The coalition of excitables is behaving as if the USPSTF recommended that no woman under 50 should ever get a mammogram. What the USPSTF said was that the decision to start early regular mammography is, given present evidence, too complicated to be the subject of a simple fiat covering the entire populace. “The decision to start regular, biennial screening mammography before the age of 50 years,” they said, “should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.”

Every woman has a different risk profile, not only for breast cancer itself, but for the legitimate harms that can arise from overdetection, ranging from excess radiation exposure to complications from needless biopsies and surgeries. It is NOT, contrary to what some of the excitables would have you believe, a simple matter of avoiding the pain of mammograms and the psychological stress from false positives. (But, at that, it might be worth asking some of the more affluent critics: if more mammograms are inherently better for you, why stop at one a year? Why not one every two weeks? What price peace of mind?)

As Steven Pearlstein observes in a brilliant column for the Washington Post, the whole spectacle is about as unedifying as could be imagined. Of course, if you’re an American against nationalized health care, or just a Canadian who appreciates the benefit of having a radically different health system just a few hours’ drive away, you can take comfort in the overpowering evidence that the American public is still not ready to relinquish the benefits of personal control over the consumption of medical services. (Even if regulation of insurance programs has rendered those benefits largely theoretical.)

But one still doesn’t like to see what one might regard as the “right” side of the debate win for the wrong reasons—namely, that Americans and their media are no longer capable of exercising rudimentary logic or understanding the most basic nuances of science. Such a passion-wracked polity cannot survive as a liberal-democratic republic for too long, with or without socialized medicine. I mourn a little when I read a passage like this in the comment section of the San Jose Mercury News:

Ironically, mammograms do save lives. The U.S. Preventive Services Task Force acknowledged as much in its report. For example, since 1990 the breast cancer mortality rate among women age 40-49 decreased 3.3 percent a year, largely due to mammograms. But breast cancer is relatively rare in that age group, so the task force decided the risks of mammograms, including false positives that lead to anxiety and unneeded treatment, outweigh the benefits.
Tell that to any woman who was diagnosed in her 40s. I know several. I bet you do, too.

An important point underlying the USPSTF’s new guideline is that breast cancer is dramatically overdiagnosed in women under 50. Incredibly, the author of this op-ed, Patty Fisher, thinks the fact she knows a lot of women under 50 who were diagnosed with breast cancer is a refutation of this! (She has also told a flat-out lie, of course, about what the task force actually said; it acknowledged that for many women, the benefits of aggressive early screening may in fact outweigh the risks.) The relevant number, for the purposes of discussing the guideline, is not simply the number of women between the ages of 40 and 49 who have been diagnosed with breast cancer because of mammograms. The relevant number is the number of women between 40-49 who would forgo mammography until the age of 50 because of their risk profile, and then die of breast cancer specifically because the lack of early detection failed to catch a truly dangerous, fast-growing tumour. And the evidence suggests that there really aren’t that many of those women.

The San Francisco Chronicle went further in the quest to put a “human face” on the debate, hunting for individual women who have had breast cancers detected in their forties. Again, without access to extensive case histories, the reader cannot judge whether application of the USPSTF guideline would have actually harmed these women. But they are personally convinced, whatever mere statistics or even the details of their own cases might say. “I can’t believe [early mammography is] not saving a lot of women,” fumes cancer survivor Laura Scanlan. “It saved me.”

Well, there you have it. The great American syllogism for the 21st century. X benefited me, therefore X must be good for everybody, and not bad for anybody. I’m every woman: it’s all in me.


 

Revolt of the booboisie

  1. you can take comfort in the overpowering evidence that the American public is still not ready to relinquish the benefits of personal control over the consumption of medical services.

    Actually, I took a more uncomfortable take. Here we have evidence that politics shall trump science even when making recommendations and guidelines — just imagine what expensive nonscientific mess will be created when politics guides the administration of their health care system itself.

    And welcome to Blog Central, Colby. At this rate, if ever Maclean's is thinking of renaming itself in some sort of tradition-busting extreme makeover, I have a suggestion: The National Post. It seems most current macleansians would have a recollection of that moniker, and it sounds like that label may soon be available…

  2. Your headline is revolting. How juvenile to refer to breasts as boobs in an article that about a disease that is killing women around the world. It isn't funny, it isn't particularly clever, and it diminishes the importance of the news it discusses. Please just stop.

    • I don't believe it's the breasts he's refering to as boobs…

      • Disingenuous.

    • MEN get breast cancer too. Boobs is appropriate.

    • Don't read much Mencken, do you?

    • Q: How many feminists does it take to change a light bulb?

  3. I agree with thrust of post but I am also inclined to give women a break. Breasts are really important to their identity as females and it is understandable if they get a bit deranged about potentially losing their breasts, or dying, from cancer. I bet us males would be freaking out as well if penis cancer was as prevalent as breast cancer is and the authorities decided to change guidelines.

    There is also interesting example of Brits, their health care service and how their 'death panels' are working at the moment. Bureaucrats have decided that it's too expensive to keep people alive, nor will it allow them to buy their own medicine because it is not fair to others.

    So it seems that whatever system your country uses, doctors are out to get you in order to save money.

    "A drug that can prolong the lives of patients with advanced liver cancer has been rejected for use in the NHS in England, Wales and Northern Ireland. The National Institute for Health and Clinical Excellence (NICE) said the cost of Nexavar – about £3,000 a month – was "simply too high".

    But Macmillan Cancer Support said the decision was "a scandal". More than 3,000 people are diagnosed with liver cancer every year in the UK and their prognosis is generally poor. Only about 20% of patients are alive one year after diagnosis, dropping to just 5% after five years." BBC, Nov 19 '09

      • Clearly It is much better to let people die than companies make a profit.

        Socialism does not pay for itself, you know.

        • It's not about profit. It's about extending what is a usually miserable existence for
          another few months. And usually because family members (not the patient) are
          having a hard time.

          • Companies are inventing cancer drugs – some may extend a person's miserable existence, some do nothing at all but at some point one new drug will cure a particular cancer or all cancers. Researchers just don't know which is which but you want to stop all that because profits bother you.

            And why is it a problem if people want to extend their "miserable existence for another few months"? Not all of us are keen to be killed off due to lack of new meds because a few people are troubled by private companies inventing new treatments.

          • There are lots of companies currently working on providing new antibiotics.

          • Oh, surely that is true. Well, not lots. Very few actually.

            But along with all that I'm sure they're all working tirelessly on the
            plague of terminal erectile dysfunction. L'il blue pill must be coming
            off patent soon.

    • "The trouble with our liberal friends is not that they're ignorant; it's just that they know so much that isn't so" Ronald Reagan

      • The same could be said of any ideologue. Conservatives are exactly the same. They care not for evidence. They’d rather try to bend reality to their world-view.

        That said, thanks Colby. I too share your despair that ignorance and irrationality rule in so many areas.

  4. Mamograms are not as infallible as some people think. My wife had breast cancer but the mamogram failed to detect it. Not only do some people get oerdiagnosed; others are underdiiagnosed.

  5. Just came across this story. I assume it is coincidence but if I was American and wanted health care reform, I would not be pleased with these stories. Women are going to be freakin' out soon and they care a great deal more about health than men do.

    "Women in the United States should start cervical cancer screening at age 21 and most do not need an annual Pap smear, according to new guidelines issued Friday that aim to reduce the risk of unnecessary treatment.

    The guidelines from the American College of Obstetricians and Gynecologists or ACOG now say women younger than 30 should undergo cervical cancer screening once every two years instead of an annual exam. And those age 30 and older can be screened once every three years.

    The recommendations are based on scientific evidence that suggests more frequent testing leads to overtreatment, which can harm a young woman's chances of carrying a child full term." Reuters, Nov 20 '09

    • So, they should have just kept over-testing despite scientific evidence showing that the risks of over testing were greater than the risks of testing less?

      I can see why people would get upset if doctors said "We should test you less frequently for disease X because these tests are too expensive". I have more trouble understanding why someone would freak out over doctors saying "We should test you less for disease X because the scientific evidence shows that the current level of testing we're doing is doing more harm than good". Creating new guidelines to reduce the COST of unnecessary treatments may perhaps be worrying, but isn't creating new guidelines to reduce the RISKS of unnecessary treatments pretty much EXACTLY what doctors should be doing???

      Would not many women be equally outraged to discover that they can no longer carry a baby to term because doctors were performing more screenings on them than were scientifically shown to be needed, and said unnecessary screenings caused irreversible damage to their bodies?

      • People are irrational. Apparently women have been told for years they should get regular cervical cancer screening and now they are being told to not do it as much. And experts said it was safe before but now expects are saying less is more.

        And it is not clear this is not a money-saving suggestion when journo writes about "reduce the risk of unnecessary treatment." Doctors might be saying the tests themselves might not be harmful but we don't want those tests to lead to even more tests and procedures.

        • I guess I'm just more trusting than you.

          When medical experts change their recommendations based on new evidence, I say "Good" not "See, they changed their minds, they don't know what they're talking about!!!!". When medical experts write a report about changing a screening regime in order to reduce the risk of unnecessary treatment, I presume the reason they're recommending a reduction in screening is to reduce the risk of unnecessary treatment. I don't start hypothesizing that maybe the journalist writing the story is just shilling to cover up their true motives.

          I just don't go looking for ways in which the experts lack of knowledge and or innate greed can be demonstrated. If they say "new evidence indicates we should do X instead of Y" I presume it's because new evidence indicates we should do X instead of Y. And when they say "We should now do X in order to reduce the risk of Y" I presume that's because the evidence they've uncovered indicates that by doing X we'll reduce the risks of Y, not that doing X will save us all money.

          I guess I'm horribly naive.

  6. Cosh!!

    Great to see you getting a wider readership for your blog posts and looking forward to seeing you in print in Macleans.

    To Macleans Mgmt: Keep up the good work here and in the magazine. Your putting together a great product and picking up Cosh while losing Kady is lke the Flames picking up Bouwmeester and kicking Bertuzzi to the curb.

    • I don't know that the analogy to the Flames is accurate unless MacLeans is also a publication with quasi-fascist overtones, staffed largely by members of a single family that consistently disappoints its supporters.

      • The Flames are quasi-fascist? Dude. Get a grip.

  7. Similarly, routine prenatal ultrasound is also ineffective. Waiting until an indication occurs before doing an ultrasound results in no statistically significant change in maternal or fetal outcomes, and reduces the mean number of ultrasounds. But people like pictures.

  8. Take a deep breath. These recommendations came "out of the blue" and represent a 180 on
    what has been drummed into everyone's heads for years – kinda like the deficit and debt hawks,
    but that's a whole other story – so of course there will be blow back. Things sometime change but
    what never changes is "the need for further study" ( I know there's a grant application around here
    somewhere).

  9. What I find most interesting is the tone and structure of the arguments for maintaing (in this case) the status quo. Those whose careers and incomes depend on the existing system (which they created by "marketing" science in an emotional manner through a full court media press) now decry rigorous scientific review which refutes their assertions. They are now appealing to the irrational fear they have created over decades of marketing "their science" to maintain their security.

    Does this sound familiar to you? On this specific issue I don't know the "truth", but the tactic sure is familiar. These misinformed minions are used as a political cudgel in all manner of current public policy planning. Pick a flash point issue and you'll see a varition of this "Downing Street Memo: make the facts fit the policy" because only we have the "public interest at heart.

    Too bad for Nietzche that his random existance has ended, he'd get a kick out of it.

  10. It's really sad that a debate about how to pay for something has been derailed so often by treatment issues.

    A lesson for all of us.

  11. Maybe they could just let individual women decide to get breast exams as often as they want..thus avoiding the whole problem…rather than going toward a public system in which government policy-apparatchiks decide what you can have based on their general guidelines??

    No two people are the same. It's better to let adults decide what care they want taken with their health.
    Of course, this requires that adults pay for that care – otherwise there will be nothing to balance the demand but limits on the supply.

    • Doctors (for the most part) know who's a higher risk and who's not. Under our system and under any system proposed by the US legislatures and bureaucrats would keep the decision-making in their hands, with the threat of lawsuits pushing them towards the side of caution.

      If we didn't pay for any mammograms and let people pay for as many as they wished without scrutiny from their doctor, all that would happen is that more affluent people would get unnecessary radiation, and the poor wouldn't get the mammograms after 50, when they'd actually be needed. Again, if someone really wants a mammogram under either our system or the American's system, most doctors will let them get one, even if they first try to talk the patient out of it.

  12. Is Colby part of the booboisie? What's his expertise anyway?!

  13. This is one of the most ineptly written, biased and clueless articles on women's health! Doesn't MacLean's have a female health issues writer or are they not paying enough…..Totally condescending and clueless. Way to go Gosh! AS for the Yankees, their twisted ideology has them wearing social and health blinders so you can't expect their govenrment to be more or less progressive. Women's health might as well represent a lepers' colony in Waziristan for these idiots to conduct proper research and do their homework on behalf of cancer survivors and the potential victims. And they're still trying to figure out that the Single Payer system in Canada costs half as much as their incompetently swollen administrative budget for health that puts the States one above Costa Rica–yet one above Slovania thankfully. They should be channeling Tommy Douglas to end this mess…

  14. Colby should get the prize for journalistic idiocy. His misogyny is showing loud and clear, aint' it.

  15. Great piece, Colby. I wonder if the fact a lot of people make a lot of money doing mammograms has anything to do with the "outrage." Actually, I don't wonder, I know. Among their many moronities, the American press forgot how to detect conflict of interest a long time ago.

    • Actually, Patrick, in the USA it's only the insurance companies that have any conflicts of interests, apparently.

  16. I suspect that someone linked to this from a crazy feminist site and we've had memi, mary and barry follow the link.

  17. A: That's not funny.

  18. Well written and spot-on. Mammograms seem to be largely unnecessary for women under 50 – individual circumstances aside – and have a fair number of downsides, the most important being excess radiation exposure due to wide-spread testing. Add in the incidence of false positives and the extra cost of such procedures, and there seems little reason to keep such tests standard.

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