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Breast cancer screening change shouldn’t be a surprise

When the United States Preventive Services Task Force decided to change its recommendation for routine mammography screening to start for women at age 50 instead of age 40, it caused quite a stir. From the considered story [1]in the NYT to the N+O, front pages were aflame this morning.

In fact, the panel’s change shouldn’t be that much of a surprise. Books like UNC Dr. Nortin Hadler’s The Last Well Person, (for a great summary on the breast cancer screening lack-of-evidence issue check out this essay [2]Hadler wrote for ABC news way back in 2007) and Shannon Brownlee’s excellent book Overtreated [3] have pointed out the limits and possible harms of some cancer screening.

Indeed, the American Cancer Society, although it hasn’t changed its current recommendations, is reported [4]to be reevaluating the evidence on certain types of screening as well.

We’ve been talking for a long time here at the Pulse about the health ramifications of overtreatment. The cost is important – as Brownlee points out, expert estimates of the amount of unnecessary care delivered in this country top $700 billion a year. By the way, that’s two thirds of the entire ten-year cost for health reform proposals now in Congress.

But cost is really a secondary issue – and this is a point that has trouble coming up in the news stories, mostly I think because people, news reporters included, have such a hard time accepting the idea that more health care, including more screening, is not always better health care. In fact, as the Preventive Services Task Force pointed out, it can actually be worse.

Take a less politically-charged example to see what I mean. A few years ago there was trend among top executives with gold-plated unlimited health plans and huge compensation packages to go in for a full-body CAT scan once a year even if they were perfectly healthy. This “ultimate screen” would presumably detect problems missed otherwise and enable early treatment.

Thankfully, this trend faded quickly. Why? A standard CAT scan gives someone the radiation dose of around 500 x-rays. Have a couple and you’re getting radiation exposure equivalent to the average dose many survivors of Hiroshima and Nagasaki received. Getting that sort of radiation when there is no need to treat you is foolhardy and will inevitably lead to further health problems. The risks unquestionably far outweigh the chances of picking up some problem that wouldn’t be caught by a family physician in a routine check-up.

In a less dramatic way, this is what’s happening with under-50 routine breast cancer screening. The scan can often be worse than the cure. What we need is great science and a clear and dispassionate look at the evidence. This is very hard. Knowing someone who had breast cancer found and treated through under-50 mammography brings a personal story to add to our intense faith in more-is-always-better medicine. It’s especially hard to think that some people who were treated for cancer didn’t need to be treated at all.

But the evidence regarding under-50 routine mammography is compelling. We shouldn’t stop routine screening because it costs less. We should stop because it is better for people’s health.