OP-ED

The Cost of Mammography Screening for Women Under 50

Goozner The tempest that greeted the United States Preventive Services Task Force guidelines on mammography screening for women in their 40s prompted the Senate to insert a mandate in its health care reform bill that every insurer cover every mammography screening test at no cost to beneficiaries. If it passes, it will spark an upsurge in mammography screening, especially among women under 50, and raise the nation’s health care tab.

The Journal of the American Medical Association this morning provides a timely article (subscription required) reminding physicians and women about the serious health costs of adopting that policy.

The authors, Dartmouth’s Steven Woloshin and Lisa Schwartz, use their trademark “number needed to treat” analysis to point out that:

  • Without screening, 3.5 of 1000 women in their 40s will die of breast cancer over the next 10 years (ie, 996.5 of 1000 will not die of the disease).
  • Screening reduces the chance of breast cancer death from 3.5 to about 3 of 1000. In other words, 2000 women between 40 and 49 must be screened annually for the following ten years to save one life.
  • For most women with cancer, screening generally does not change the ultimate outcome; the cancer usually is just as treatable or just as deadly regardless of screening.
  • Finding cancers that were never destined to cause symptoms or result in death is the biggest problem with mammography, especially among younger women. Since it is impossible to know which cancers caught early are benign, all are treated with surgery, chemotherapy, radiation, or some combination. Over-diagnosed women undergo treatment that can only cause harm, and must live with the ongoing fear of cancer recurrence.
  • While only 7% of women believe there could be breast cancers that grow so slowly that leaving them alone would not affect their health, randomized clinical trials have consistently shown that the groups undergoing mammography have more breast cancer, even after 15 years of follow-up. This persistent difference represents over-diagnosis.
  • Estimates of the rate of over-diagnosis range from 2 women over-diagnosed for every breast cancer death avoided in one trial, to 10 to 1 in another.

companion piece by Steven Woolf of Virginia Commonwealth University points out that the guidelines recommend physicians discuss these relative risks and benefits with women before proceeding with annual mammograms. It wasn’t a blanket call for a ban.

Advocates of mammography and cancer survivors often belittle these harms, but a moral duty exists when subjecting millions of asymptomatic women to a procedure that benefits relatively few. Whether hundreds of women should endure the consequences of inaccurate mammograms to save 1 woman’s life is a legitimate ethical question.

“The politicalization of medical care is wrong,” the Woloshin and Schwartz conclude. “Promoting screening irrespective of the evidence may garner votes but will not create healthier voters. It may do the opposite.”

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12 replies »

  1. I am an RN. I am a woman. I realize that there may be long-term affects from radiation; however,there are no recent innovative ways to screen for breast/ tissue cancer. Technology has definitely lagged in this therapeutic area.in the meantime, I will continue to get mammography screenings. The literature points that way.

  2. Margalit, you don’t see a problem with the government forcing insurers to cover yearly mammography for all women 40+, but the fact is that this goes against medical evidence. The Task Force stated this clearly, and it has been known for years that women under 50 actually have HIGHER breast cancer mortality when they are screened (vs unscreened) – please see: http://jnci.oxfordjournals.org/cgi/content/short/95/20/1508
    The problem is that women have been lied to about the benefits of screening mammography, and practically no one knows anything about the downsides of screening. Breast cancer victims routinely attribute their survival to screening mammography, but it is far more likely that they endured mutilation, irradiation and poisioning for a benign condition that had no potential to harm them at all.
    Women need the correct information to make an informed choice, yet doctors literally never mention that screening mammography makes a breast cancer diagnosis far more likely. Screened women are at least 30% more likely than unscreened women to lose a breast and endure the toxic treatments that may themselves shorten life. The PROBLEM is that only the benefits of screening mammo are discussed, and HARMS are never even mentioned. This is immoral, just sick. It’s like the cancer industry thinks every breast is theirs to slice up and irradiate as they please. Yes, it’s a BIG PROBLEM!

  3. rbar, for that minuscule fringe segment, I would suggest a different sort of “screening”… 🙂

  4. Margalit,
    Of course few women get superfluous mammograms “casually”. They get them because they feel that they are preventing disaster by choosing screening. Not unlike moms who take daily cellphone pics of their children, in case they get abducted that day.

  5. I’ve said in other blogs that the best way to get insurance companies “out” of this discussion (“Should I (an average risk female under 50) have a mammogram?”) is to not cover them.
    I assume there would be great demand and that would push down the costs of routine mammography. I would wager it would bring the cost down to about $50.

  6. Dr. Watkins, I would expect physicians to do their part and act responsibly in their recommendations. Maybe I am deluding myself, but I think most doctors are basically honest, and certainly not intent on harming patients.
    If you create an environment where doctors and patients are encouraged to game the system, they most certainly will. If screening mammograms are not covered, you will see an insurgence in diagnostic mammograms, and there are plenty unverifiable ICD9 for that.
    In my opinion the key word here is “routine”. As far as I know, nobody is asserting that screening mammograms should never be performed before the age of 50, but only that they should not be routinely performed. This implies to me that ordering a screening mammogram is a, case by case, medical decision and I would expect it to be left to a physician.
    There should of course be some recourse for restraining physicians who, routinely, order/perform unnecessary tests and procedures for financial gains, but that is a much larger subject.

  7. Like Gary Schwitzer, I believe Merrill Goozner did a goo job summarizing the piece.
    As the authors wrote:
    “…people need balanced information. Simplistic slogans touting only the benefit are deceptive. Simple, standardized summaries (and they provide a table of some) about the benefits and harms of testing would help foster good decision making.”
    That’s something journalists struggle with every day in telling health care stories – as is shown over and over on HealthNewsReview.org

  8. “Once the patient and doctor made their informed decision, the insurers should pay for whatever they decided to do.”
    Would you apply the same standard to yearly CT scans for smokers? Laminectomies for non-radicular back pain?
    Laporoscopic debridement for joint arthritis? (all shown to be ineffective)

  9. I’m sorry Merrill, but there is something very dissonant about the continued mammography storm in a tea cup, mainly because both sides are correct and there really is no conflict.
    Physicians and their patients should carefully consider the evidence and the risks before undergoing any testing, not just mammography (PSA comes to mind). Once the patient and doctor made their informed decision, the insurers should pay for whatever they decided to do.
    I don’t really see a problem here, unless you believe that insurers should have the right to override both patients and doctors and dictate medical treatment choices, mainly for those that don’t have the means to pay outside the system.
    I think proper dissemination of the newest evidence will actually cause a drop in mammography rates regardless of payment policy.
    I personally don’t know any women that will casually go get a couple of mammograms just because they are free.

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