What's the big deal about the new breast and cervical cancer screening recommendations?

New guidelines for cervical cancer screening coming close on the heels of recommendations by the US Preventive Services Task Force that routine mammographies be delayed until age 50 and then repeated every 2 years have created dicussion and apparent controversy about screening. Disclosure: Maxine knows a little about cancer because she had it seven years ago and is mercifully disease free today. For this reason, she feels she may be able to weigh in on this controversy as both a (girl) economist and as a cancer survivor.

In some ways, this is similar to the controversy that arose when the Women's Health Initiative (WHI) released their report indicating hormone replacement therapy (HRT) in post-menopausal women elevated risk of cardiovascular disease, including stroke, and breast cancer. Elevated risk of mortality among women taking estrogen plus progestin persisted three years after the study was halted although the causes of the death changed. In addition, women taking estrogen plus progestin were at increased risk of stroke and diminshed cogntive function.  The findings produced considerable controversy. An article about the controversy (co-authored by several of Maxine’s friends) docments the many interest groups that contributed to and benefited from the controversy, not least of which were the drugs manufacturers for whom HRT represented significant revenues. Wyeth, manufacturer of Premarin® saw revenues plummet from $2.5 billion per year to around $260 million per year after WHI released the first study results.

Physicians entered the fray on several fronts. Some acted as patient advocates because women were reluctant to return to a life of hot flushes and because they (falsely) believed that HRT represented a sort of “fountain of youth.” However, many who weighed in publicly had financial ties to drugs manufacturers (see the Institute of Medicine report on Conflict of Interest in Medical Research, Education, and Practice, particularly here). In an interesting example of collusion between physicians and drugs manufacturers, Wyeth had arranged for and paid physicians and others to ghostwrite many articles published in medical and scientific journals that reported benefits, but few harms, for HRT. The physicians whose names appeared on the articles did not disclose their financial relationship with Wyeth.

Now we have a Federal task force recommending fewer screenings that should be performed later in life than had originally been recommended and controversy has erupted. As with HRT, it helps to think about the interest groups involved. Radiologists and oncologists benefit financially from early and excessive screening as do medical laboratories.  Even when there is little or no benefit for women, these groups will benefit by the reimbursed amount for each test or procedure (net of the marginal cost of each test or procedure). Hospitals and surgeons benefit from unnecessary biopsies as long as reimbursed amount exceeds marginal cost. Drugs companies benefit from the revenues associated with sales of chemotherapeutic agents, breast implants, antibiotics, and other drugs associated with cancer treatment. Presumably, the revenues from chemotherapeutic agents, etc, renders a very real benefit in lives saved, but the uncertainty of cure or remission makes this trade off less straightforward. And women benefit when cancer is detected early because they (presumably) have a better chance of treatment leading to remission or cure. The argument that early detection improves survival is difficult to prove because we have no counterfactual (i.e., a group of women who are detected early but not treated) with whom to compare early detected, treated women.

In evaluating “controversies” from recommendations based on research findings, the first question Maxine always asks is: who benefits financially? She is especially skeptical when more of something is recommended. In the present case, less is being recommended and this alters her perspective somewhat. Clearly the usual suspects do not benefit financially from the recommendation. The nation as a whole may benefit if reductions in unnecessary screening and tests slows the rate of growth of medical expenditures. (There’s no guarantee it will do this if providers simply increase other services to offset losses from this change in policy, but it is a step in the right direction).

The new recommendations place the focus squarely on women’s welfare. They are the ones most likely to be harmed by a reduction in screening. Or are they? The point of the task force is that statistically speaking, a woman’s individual risk of having an undetected cancer is quite low if the new screening policy is adopted. It should be noted that the new policies still recommend screening for high-risk women, those with a family history of breast cancer, for example.

It is the uncertainty about benefits and harms in combination with the statistical probabilities of detection and death (which also derive from uncertainty) that make recommendations of this sort difficult to formulate and evaluate. Added to this is an attitude about consumer sovereignty that is unique to the US.  If a woman fears cancer (no matter how irrationally) and wishes to be screened, she should be able to do it and have her insurance company pay for it. Perhaps fortunately, the medical marketplace doesn’t work like this. Docs are gatekeepers. Insurance companies raise financial impediments. Consumers are largely uninformed as the complexity of their disease and treatment increase.

The groups that have made the new recommendations for breast and cervical cancer screening represent the best science at this time interpreted by individuals who are trained in scientific methods. Group members’ conflicts of interest appear to be transparent.

The tension in medicine whether delivered or financed publicly or privately will always be between individual autonomy to demand screening at any age, scientific evidence that screening of low-risk women under 50 yields little benefit either to the woman or society, and societal resouce constraints in which unnecessary screening and associated costs translate into lost opportunities for investment in other socially and individually beneficial resources like education, expanded health access, and improved infrastructure to name a few. Resolving these tensions intelligently is the "big deal" in health and public policy.

 

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Here's a more populist take on this issue, which you may be interested in.
http://tpmcafe.talkingpointsmemo.com/talk/blogs/san_fernando_curt/2009/11/ounce-of-prevention-on-starvat.php

[Maxine Udall (girl economist)]

Maxine is no expert on health insurance nor does she have much trouble believing that HI companies' main objective is profit max, but she doubts that the release of the two recommendations are part of an insurance company plot to discredit health reform efforts or the public option. To the contrary, it is far more likely that this is an example of the guvmint shooting itself in the foot at the exact wrong moment. (Which is why some, including Maxine, are skeptical about the guvmint's ability to manage health care delivery and costs. Maxine differs from most of the skeptics on this front by believing that we are evolving to a new, more sustainable economic model in which the public sector can actually become more efficient and responsive than the private sector in the production, financing and/or delivery of some goods and services under circumstances that at present are not well understood. This year's Nobel Memorial Prize in Economics was shared by two people who have likely laid some of the ground work for the new model.)