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Science-Driven Medicine Bumps Up Againt Perception of Risk with Mammography

Posted Nov 23 2009 10:02pm

The recent recommendation of a panel of experts that routine mammography is no longer necessary for women in their 40's was greeted by widespread skepticism and will probably be ignored by most physicians and patients. My personal interpretation of these events is that most women viewed early detection of breast cancer as trumping the "problems" associated with false positive reports. For those with health insurance, the cost of care for many does not play a large part in this decision process. The New York Times published a short but excellent analytical piece about this issue with a look at the future (see: Medical Science and Practice in Conflict ). Below is an excerpt from the it:

This week, the science of medicine bumped up against the foundations of American medical consumerism: that more is better, that saving a life is worth any sacrifice, that health care is a birthright.... The backers of science-driven medicine, with its dual focus on risks and benefits, have cheered the elevation of data in the setting of standards. But many patients — and organizations of doctors and disease specialists — find themselves unready to accept the counterintuitive notion that more testing can be bad for your health....For decades, the medical establishment, the government and the news media have preached the mantra of early detection, spending untold millions of dollars to spread the word. Now, the hypothesis that screening is vital to health and longevity is being turned on its head, with researchers asserting that mammograms and Pap smears can cause more harm than good for women of certain ages....The challenge of persuading patients and doctors to accept such standards requires a transformational shift in thinking, particularly when the disease involved is as prevalent, as deadly, and as potentially curable as cancer. How do you convince them that it is in their best interest to play the odds when they have been conditioned for so long to not gamble on health? After all, for the one in 1,904 women in their 40s whose life would be saved by early detection of breast cancer, taking the risk would in retrospect seem a bad choice.

I was fascinated by the author's use of the term "science-driven medicine" -- I will take it to be largely synonymous with evidence-based medicine (EBM) with some overlap with comparative effectiveness. I have an image of a panel of experts poring over research articles, weighing the data, and concluding that the earlier screening was not cost-effective. Organizations with the most financial skin in the game such as the American Cancer Society and the American College of Radiology were the first out of the gate, decrying the evidence and the conclusions of the panel. The women of America as the consumers of the service then weighed in aggressively in favor of the earlier screening -- whatever evidence was present to support the conclusion was left in the dust.

So the question for health and lab professionals is whether this is a general vote in favor of early screening and against EBM and comparative effectiveness as tools and analytic methods for the future. I think that the answer to this question is probably no because of some of the unique aspects of mammography in particular and women's breast health in particular. Breast screening in so ingrained in our culture through long-standing practice that it will be nearly impossible to alter in any substantial fashion. However, any health panel recommendations in the future may need to take the individual wishes and perception of healthcare consumers into consideration. For me, this is the major lesson that has now been learned.

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