Fri, 2 Sept. 2011 - 3:44 p.m. MT
Credit: ARA Staff - American Running Association
Kerianne H. Quanstrum, MD, and Rodney A. Hayward, MD, writing in the September 9, 2010 issue of the NEJM, point out a central but too-often unexplored conflict within the current health care debate. Since 2002, annual mammograms have been recommended for women 40 years of age or older. Suddenly, an independent and government-funded panel suggested that this schedule might be too much—that less might be better.
Radiologists and other advocates of breast-cancer screening immediately denounced the panel’s statements, attacking “government rationing”-type cuts, and even suggested that the panel members had ignored medical evidence.
In reality, this independent Preventive Services Task Force (PSTF) simply recommended that routine screening begin at the age of 50 years, whereas women between the ages of 40 and 49 years should make individual decisions with their doctors as to whether their risk factors mandate a mammography. The panel also recommended that mammograms be performed every other year, which they said would reduce the harms of mammography by nearly half while maintaining most of the benefits. The panel concluded that we had previously overestimated the value of mammography.
The statistics favor the PSTF’s review and revision of current screening expectations and attitudes: More than 1,900 women would need to be invited for screening mammography in order to prevent just one death from breast cancer during 11 years of follow-up. For women between the ages of 60 and 69 years, by contrast, fewer than 400 women would need to be invited for screening in order to prevent one breast-cancer death (during 13 years of follow-up).
The net benefit of all medical treatments relies on three factors: risk of death if untreated, the treatment’s relative risk-reduction, and the treatment’s risk of harm. A lesser risk of no treatment means the net benefit of treatment will increase, even if the treatment’s relative risk-reduction stays the same. Simply put, doing nothing sometimes has its advantages. For many interventions, if the risk of no treatment is low, then the side effects and risks of treatment will dominate, and the treatment will result in net harm.
Assessing what to do, then, is necessarily a value judgment—it is the very definition of one. As the authors very candidly write, “When either side in the mammography wars claims that the evidence suggests that women should or should not undergo routine mammography starting at the age of 40 years, they are deceiving themselves and the public about what the evidence can tell us. They are really just making different value judgments about where to set the threshold.”
They continue later, “In the United States, where medical specialists often enjoy an exalted status in the minds of the public, if experts shout loudly that every woman 40 years of age or older must be screened annually for breast cancer, then breast cancer must be important, screening must be a basic human right, and doctors who provide this service must have great value and authority.”
But what if those experts are basing their recommendations on more than the interest of patients alone? “In any other industry, we accept the idea as natural that those providing a service or product hold their own and their shareholders’ interests as a primary objective. Why have we failed to acknowledge that the same phenomenon occurs in health care?”
The NEJM commentary is quick to point out that of course individual medical providers care deeply about their patients. But to pretend that the guild of health care professionals
has other than a primary responsibility to promote its members’ interests is wishful thinking.
Doctors Quanstrum and Hayward are aware that self-interest is not in itself a bad thing. It is a force for productivity and efficiency in any market. But it is folly to expect the guild of any service industry to harness its self-interest and to act according to beneficence alone—as they put it, “to compete on true value when the opportunity to inflate perceived value is readily available.”
So what can be done? Making an example of mammography is just that—an example of a ubiquitous and unspoken-about trend in today’s health care system. Sweeping legislation about coverage for millions of Americans won’t solve the fundamental issue: the health care system remains for-profit.
“It is for this reason,” they write, “that some degree of market regulation is necessary, such as truth-in-advertising and antitrust laws. It is only in health care that we have failed to recognize the need for analogous protections. It is only in health care, after all, that the same group that provides a service also tells us how valuable that service is and how much of it we need.”
Their commentary calls for general practitioners with evidence-review-and-synthesis expertise, operating on panels formed around a given question or process of care. These independent panels could then seek input from the relevant clinician groups—a kind of Supreme Court of Medical Practice. In an age when the boundaries between capital interests and the public good are constantly, even predictably, obscured, this sincere and bold call to action from these enlightened physicians is welcome indeed.
NEJM, 2010, Vol. 363, No. 11, pp. 1076-1079, http://www.nejm.org/doi/full/10.1056/NEJMsb1002538
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