Personal stories of the kind, “I would not be alive if a routine screening mammogram had not detected my breast cancer,” dominate the letters to the editor after any news of research or policy proposals that favor less use of such mammograms. What kinds of responses can be made on public health and ethical grounds to such letters?
First consider a recent, well-known case:
In 2009, the USPSTF (United States Preventive Services Task Force) updated its advice for screening mammograms. Screening mammograms, or routine mammograms, are X-rays given to apparently healthy women with no symptoms or evidence of breast cancer in the hope of detecting the disease in an early, easily treatable stage… The previous advice was for all women over the age of 40 to receive a mammogram every one to two years… The Task Force recommended against routine mammography to screen asymptomatic women aged 40 to 49 years for breast cancer. Patients in this age group should be educated about the risks and benefits of screening, and the decision whether to screen or not should be based on the individual situation and preferences. The old advice was based on “weak” evidence for this age group. The new advice is based on improved scientific evidence about the benefits and harms associated with mammography and is consistent with recommendations by the World Health Organization and other major medical bodies. Their recommendation against routine, suspicion-less mammograms for younger women does not change the advice for screening women at above-average risk for developing breast cancer or for testing women who have a suspicious lump or any other symptoms that might be related to breast cancer. (Source: wikipedia)
Otis W. Brawley, chief medical officer for the American Cancer Society (ACS), responded for ACS. His commentary included a sentence widely quoted since: “With its new recommendations, the USPSTF is essentially telling women that mammography at age 40 to 49 saves lives; just not enough of them.” Brawley hints at a benefit/cost issue in the USPSTF recommendations—the benefits of the lives saved is outweighed by the costs (of screening, follow-up investigation of false positives, unnecessary treatment of slow-growing cancers, etc.)—but his words also seem to imply, accusingly, that the USPSTF is prepared to let a number of unscreened 40-49 year old women die of breast cancer—like the writers of the letters to the editor but now multiplied by the thousands.
Neither Brawley nor any letter writer, to my knowledge, has followed the logic of their rejection of the USPSTF proposal. If just one life saved by screening mammograms of 40-49 year old women justifies such mammograms being routine, how can they justify not having routine mammograms of 30-39 year olds? After all, there are women in that age group who get breast cancer and go on to die from it. In not advocating such screening is the ACS saying “mammography at age [30 to 39] saves lives; just not enough of them”? Similarly for 20-29 year old women[i]. And 10-19 year olds. And for 0-9 year olds. (Yes, breast cancer sometimes occurs in young girls.)
If this logic were pointed out to the letter-writers, they might agree that such screening for all ages should take place. Some of them might go on to get involved in a campaign to that end. Trying to convince insurance companies and government policy-makers to provide the necessary funds would, I predict, expose limits to the support to be gained from those who had been their allies in maintaining the practice of routine screening for 40-49 year olds. Insurance companies and government policy-makers would, I suspect, end up invoking benefit/cost arguments when faced with extension of such screening to other age groups—Healthcare funds are not unlimited and so they need some basis for choices about their allocation.
Yet, allocation of health care funds according to benefit/cost calculations cannot be expected to satisfy the person with the story about screening saving their own life. The next post considers a different angle to approach the incommensurability of the individual experience and the net social benefit.
[i] Indeed, a local newspaper that highlighted Brawley’s quote also featured a story about a recent high-school graduate recovering from breast cancer discovered (by self-examination, not by mammogram) when she was 23.