The Mammogram Melee: How Much Screening Is Best?

Why the furor over the new screening guidelines could be a sign of things to come

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Women's breasts are not the usual topic of public discourse in Washington, at least not outside the context of a scandal. But for the past few weeks, the question of when women should be screened for breast cancer has become the subject of intense medical debate, partisan congressional bickering and a whole lot of confusion among mothers, daughters, sisters and friends, not only inside the Beltway but throughout the rest of the country.

On Nov. 16, the 16 members of the independent U.S. Preventive Services Task Force recommended that most women delay routine mammograms until age 50 (instead of 40, as the panel advised in 2002). The task force cited enhanced analysis of the risks and benefits of screening as the reason for the new guidelines. But the recommendations went straight to the heart of the emotionally charged debate over the Democratic-sponsored health care reform legislation that is working its way through Congress. Republicans like Representative Marsha Blackburn charged that "this is how rationing begins. This is the little toe in the edge of the water." No one was more surprised, or less prepared, for the uproar over the new guidelines than the advisory panel itself. As a result, the merits of what the group is now recommending have been obscured by all the political smoke. Dr. Diana Petitti, a professor at Arizona State University and vice chair of the task force, says, "Our attempt to communicate [the risks and benefits of] routine screening was definitely lost."

The rumblings over the mammography message provide a useful window into why U.S. health policy does not always dovetail with the best available medical evidence, and certainly not with the best available data on costs. By and large, American patients (not to mention politicians and cancer advocacy groups) still subscribe to the view that every life is worth saving, no matter the cost, and that when it comes to prevention, screening is always good and more is always better. For decades, patients have been steeped in the notion that frequent screening is not just beneficial but also essential to the early detection of cancer. But such personal calculations do not apply in the same way to an entire population, where the benefit to some must be weighed against the harm to others.

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