Changing mammography guidelines and insights into health care reform

By Robert Troug, MD, executive director of Children’s Hospital Boston’s Institute for Professionalism and Ethical Practice and director of Clinical Ethics in the Division of Medical Ethics at Harvard Medical School. mammogram

Last week, I wrote a commentary in the New England Journal of Medicine on recent guidelines for routine mammography screening published by the U.S. Preventive Services Task Force. In it I described why the concept of rationing, which has been a dirty word in the American health care debate, is actually essential if we are to develop a health care care system that makes sense, is affordable and delivers the best possible health care to all of our citizens.

In their guidelines, the Taskforce recommended that routine mammography screening for women should begin at age 50 rather than the previously recommended age 40. As I read the report and reviewed the data, I was drawn toward what seemed to be contradictory conclusions.

On one hand, the data clearly show that screening women in their forties saves lives. In this age group, about 1,900 mammograms are required to save the life of one woman. And although false positives are a significant problem, only five biopsies are required for every case of cancer found. This seems like a pretty good deal to me, and I can understand why women’s advocacy groups have called for no change in the guidelines.

But other data made me realize that while screening women in their forties might be the right choice from the perspective of an individual woman, it is probably the wrong choice from the perspective of our health care system overall. It turns out that adherence to the current guidelines from the American Cancer Society (which include screening women in their forties) costs more than $680,000 for every year of life saved. This is more than 10 times the amount that is thought to be affordable within the health care budget of wealthy countries like our own. In other words, while we could probably make an exception and continue to offer screening to women in their forties (as the Obama administration has pledged to do, under pressure from its Republican critics), in the long run these kinds of decisions will drive us to bankruptcy.

As our country debates health care reform, this issue presents a stark example of the tragic choices we must confront. Any health care system that is both effective and affordable will have to forego certain types of care that unquestionably save lives, but at too high of a cost. While these decisions may seem unbearable, they are unavoidable.

There is a silver lining to this dark cloud, however. If the money saved from these more sensible screening guidelines were devoted to research and improving the treatment of breast cancer, it is likely that more lives would be saved in the long run.