In a past life...

I was a research assistant studying how to improve cancer screening in low-literacy patients in New Orleans. I knew the cancer screening guidelines for breast, cervical and anorectal cancers like the back of my hand. So, the recent spate of revised guidelines is very interesting to me, especially when I hear of them being used politically...

Guidelines Push Back Age for Cervical Cancer Tests
Culture Clash in Medicine
Mammogram Debate Took Group By Surprise
The Controversy Over Mammograms
Panel Urges Mammograms at 50, not 40
GOP Uses Mammogram Study to Attack Health Bill

I'll start off by saying that I am a big fan of using research and evidence-based practice to inform health decisions and policies. I'm a little biased that way. Unfortunately that does not seem to be the case with most health decisions, especially in the United States, where we have an extremely sophisticated health system that still fails millions of people a year.

I also surprises me that the GOP is using these new recommendations to attack the health bills and President Obama. The councils that reported the new recommendations are independent organizations, one a federally appointed advisory panel, the other the American College of Obstetricians and Gynecologists. When we are looking for ways to improve health care and reduce costs, shouldn't we look to recognized experts in deciding where those changes can be made? Instead, the GOP (who, in my opinion, hasn't been a stalwart of women's health) claims the new guidelines are just a guise to create health rationing. But, don't we already have some form of health rationing in place? Medicare pays for one mammogram every 12 months, beginning at age 40, with one baseline mammogram for women between 35 and 39 years old. These rations (because they ARE rations for women who have Medicare) are based on guidelines with broad consensus from the American Cancer Society, the American College of Physicians, the National Institutes of Health, and others. When these same organizations change their consensus (which, to note, has not been done with the U.S. Preventive Services Task Force's new recommendations), I believe Medicare services should follow. No one (not even the those crazy health-rationing folks in the Democratic party) wants to create more morbidity and mortality from breast cancer. If for no other reason then that it's expensive. Cancer treatment is not cheap and, like most health problems, is easier to cure (and cheaper) when caught early.

I think people fail to realize the wonderful thing about recommendations. They are just that. They are not mandatory laws with no room for patient differences or doctor opinions. Even the old guidelines had important clauses. Women with higher risk, such as those with a first-degree relative with breast cancer or those with the BRCA gene, were recommended to start screening earlier. And, let's face it - how many women actually followed the guidelines? According to the Kaiser Foundation, only 76.6% of women aged 40+ had a mammogram in the past two years (2006).The American Cancer Society reports similar statistics: for women 40-49, the percent who had a mammogram within the past two years is 63.5%; women 50-64, 71.8%; and women 65+, 63.8%. But these numbers drop when looking at mammograms within the past year (the guidelines currently suggested by the ACS): women 40-49, the rate is only 47.8%; women 50-64, 55.5%; and women 65+, 50.2% (2009, click Breast Cancer Facts & Figures 2009-2010 to download the pdf report).

Finally, I'd like to go back to the basic principles of screening. Screening is a very basic public health strategy, used in a population to detect disease in people without symptoms. The point of screening is to reduce morbidity and mortality from the disease in a population. The ultimate question in deciding whether to implement screening and its frequency is to determine when anticipated benefits outweigh anticipated risks in a population. This is why there has been so much understandable debate with cancer screening - screening is based on populations, not individuals. While screening every two years after age 50 might be better at the population level, it might be detrimental to some individuals. That's where patients and doctors play the most important role in determining what is best. So, maybe the key to improving our health care is to have a system in place that allows for the use of best practices, incorporating population-level guidelines and individual decisions.