New Mammogram Standard: How Much is Your Life Worth?

In recommending “against routine screening mammography in women aged 40 to 49 years,” the U.S. Preventive Services Task Force is clearly weighing potential lives saved against the money needed to save them.

The task force recommended against screening because it concluded that there was “moderate evidence that the net benefit [of screening mammograms] is small for women aged 40 to 49 years.” The documents supporting its decision review selected literature on mammography and breast cancer survival. They show that mammography reduces the risk that women aged 40 to 49 will die from breast cancer about as much as it reduces the risk that women aged 50 to 59 will die from breast cancer. According to one of the supporting papers, screening produces a 15% reduction in breast cancer mortality in both groups.

What are the costs that the Task Force measured against the benefit of a 15% reduction in mortality in order to come up with its “small net benefit?”  No one knows because they don’t say.

Radiation risks are said to be very low and the pain and anxiety associated with the procedure are manageable for most people. Overall, the Task Force’s supporting papers say that  adequate evidence suggests that the overall harms associated with mammography are moderate for every age group considered, but that “false-positive results are more common for women aged 40 to 49 years.” How much do the false positives cost? It doesn’t say.

Nonetheless, one can infer that the false positives are the real reason for the Task Force recommendations. One of its references, a paper in the Annuals of Internal Medicine,  reports on the results of 6 models that estimate the outcomes of breast cancer using various assumptions. That paper states that:

If the goal of a national screening program is to reduce mortality in the most efficient manner, then programs that screen biennially from age 50 years to age 69, 74, or 79 years are among the most efficient on the basis of the ratio of benefits to the number of screening examinations. If the goal of a screening program is to efficiently maximize the number of life-years gained, then the preferred strategy would be to screen biennially starting at age 40 years. Decisions about the best starting and stopping ages also depend on tolerance for false-positive results and rates of overdiagnosis.

In other words, to save the most lives, you screen the 40 to 49 year olds. To save money by getting rid of pesky false-positives that require follow-up visits, you don’t. Medical researchers have long known that the cost of screening per life saved is lower for women in their 50s than for women in their 40s. But should money be the determining factor?

The main difference between U.S. health care and health care of other developed countries is that the U.S. is concerned with saving lives. Other countries are more likely to balance medical benefits against economic costs. That is why U.S. women get more Pap smears and more mammograms, and have better cancer survival rates.

As health reform legislation wends its way through Congress, two things are worth keeping in mind: (1) The federal government will determine what kind of health insurance everyone must have, including such screening benefits as mammograms and Pap smears, and (2) 15 years ago what helped kill health reform was Hillary Clinton’s decision to mandate from the White House which women would be eligible for such tests and at what age and how often.

Comments (15)

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  1. Devon Herrick says:

    Virtually anything the U.S. Preventive Services Task Force decides will be a political decision. It would be hard for it to be any other way considering 88% of medical bills are paid for by someone other than the patient. The government currently pays for 46% of health care expenditures. Thus, if the Task Force errors on the side of caution, insurers will conclude it’s akin to an unfunded mandate. If the Task Force issues a conservative recommendation, advocates will lament that women are dying because of money.

    However, if people were making the decisions (and paying the bills), the Task Force could render an opinion and women could decide the risk and benefits for themselves.

  2. Juan O. says:

    Sounds a lot like rationing to me…

  3. hoads says:

    This is just the tip of the iceberg and I believe this was a “trial balloon” to ascertain the public’s reaction to the “less is more” Obamacare ideology embedded within the Senate Healthcare Bill concocted behind closed doors. I know in the first edition of the Baucus Bill there was a section described as a “regional imaging board” that was to oversee imaging studies.

    It should be obvious to those who pursue information not forthcoming within MSM that technology that looks inside the body to find abnormalities will be heavily regulated. No need to treat cancers unseen.

  4. Vicki says:

    Very good post. So-called health reform is geting more and more worrisome.

  5. Nancy says:

    I agree with all of the above. This is awful.

  6. John Goodman says:

    The Wall Street Journal has a great editorial on this very topic this morning.

  7. hoads says:

    It is so blatantly obvious what Obamacare is all about–taking healthcare dollars from one entitlement (Medicare) to create another entitlement spread over the population except, this expanded entitlement will come with so many strings attached that people will not realize they’ve been had until years down the road when explicit rationing will be rule. But, Dems are exploiting the ignorance of the majority healthy people who do not realize that they are exchanging their future healthcare needs when they really need it for the “security” of healthcare coverage today.

    Everyone should read this:

    I think this might shed some light on the left’s ideology that is driving the healthcare debate especially when considering Obama’s quest to align us with international objectives at the expense of our individual freedoms and our country’s sovereignty.

  8. John R. Graham says:

    This has been a long time coming. Some think that the increased “anxiety” and extra biopsies cost more than women actually dying of breast cancer. If you reduce the number of Type II errors (which the U.S. does) you are going to increase the number of Type I errors. This isn’t surprising. Indeed, “society” seems to accept many tests that attempt to eliminate Type II errors entirely and are riddled with Type I errors. (As you know if you have been standing in the airport security line recently, where everyone with stainless-steel cufflinks gets pulled aside! Or, look at the whole global-warming hysteria!)

  9. Curtis Bennett says:

    I just lectured in a medical academic program in Toronto showing advanced infrared applications being able to see breast cancer. The program showed men with breast cancer, discussed a 10 year old having a breast removed as well as the toxic load in our bodies causing cancer!

    Waiting till 50 for breast screening is ridiculous and unnecessary but very very troubling to see why a government of the people for the people would think that was responsible health care. Prevention or huge costs after the fact but we are not discussing the 100% toxicity ratio where cancers are the result.

    Shame on us for putting a dollar before our mothers.

  10. Larry C. says:

    There is a front page article, above the fold, in the New York Times this morning with this news: they are also changing the guidelines on Pap smears.

    Guess in which direction the change is going? If you guessed spend more to save more lives, you get an F on this exam.

  11. […] well-informed observers (including Linda Gorman and the Wall Street Journal) saw the recommendation to reduce mammography as a harbinger of […]

  12. John Goodman says:

    Gina Kolata has a good history of the controversy — year by year:

  13. John Goodman says:

    More from Gina Kolata: Only 15% of breast cancers need to be treated and can be cured:

  14. John Goodman says:

    Why is everyone ignoring the men? The USPSTF has already backed off of PSA testing. See Washington Post article here:

  15. […]  Because one man’s unnecessary test is another man’s sensible risk reduction, figuring out whether the US health care system conducts “too many” tests is harder than it looks. Comparing tests ordered by fee-for-service or managed care physician groups may miss the fact that patients self-select into different practice management styles. It is difficult to even define an unnecessary test or referral: A previous post at this blog discusses the problems inherent in defining “unnecessary” mammograms. […]