Thursday, December 3, 2009

Less Cancer Screening is a Technocracy, not Discrimination

To be very clear about this, there have been nearly equivalent studies showing that early prostate cancer screening doesn't do much to reduce prostate cancer mortality. No one said anything about these studies giving men an excuse to take the a heteronormative "tough it out" approach and avoid seeing a doctor. Dana Milbank didn't write columns with quotes from stunned advocacy and awareness groups. Prostate cancer survivors in the Senate like John Kerry and Chris Dodd didn't demand amendments that mandated full first dollar coverage for current levels of PSA screening (in fairness, Senator Mikulski has rolled back the language to allow the hope of some flexibility hear, if at some point the relevant agency can change their recommendations without creating a firestorm on Capitol Hill or in the White House). Tom Coburn didn't start making shit up about how the Democrats would tax your ... well, I think my readers have gotten the picture.

America has two problems relating to breast-cancer screening. One is the inequity in access to screening; poor and/or non-white women are less likely to get screening than middle-class and/or white women. The other is that those women who do get screening receive frequent and early screening that ends up detecting a larger number slow-growing, non-fatal than peer countries. In addition, mammograms in general produce a lot of false positives, so we're putting lots of patients through a lots of anxiety and unpleasant treatment that's not saving very many, if any, lives. In the UK, women at standard breast cancer risk (no BCRA, no family history of breast cancer) are guaranteed one mammogram every three years starting some time between 50 and 53 (women at elevated or high risk are guaranteed US levels of screening). France (which has the #1 quality health care system in the world) offers breast cancer screening starting at age 50 every two years. Germany? Same as France. The rest of the industrialized world seems to think that the harms caused by early screening—and let's be clear on this, complications due to treatment of a non-fatal cancer are definitely harm—outweigh the benefits. This isn't discrimination, this is going where the evidence is taking us. Yes, that line has abused by pro-discrimination types throughout history. But that doesn't mean that every time it's used, there's discrimination afoot.


Thomas said...


As a technical note: the problem with mammograms at early ages isn't so much that they detect slow-growing tumors that won't kill you anyway. It's more that they detect fast-growing tumors that will kill you anyway. Either way, the conclusion is the same.

On the main point: I think it's amazing how a report from the American Cancer Society, one of the biggest genuine disease advocacy groups, is being treated as if it were Republican astroturfing. Daniel Shaw, on NPR a couple of weeks ago, said that the reaction was an illustration of how people didn't trust government anymore, and even he didn't point out that this *wasn't* government.

Nick Beaudrot said...

Where's the ACS report you speak of?

Nick Beaudrot said...

Maybe my terminology was off.

I skimmed a study that compared mammogram regimes in the UK to the US. In the UK they have a much lower recall rate. The researchers had various theories as to why this is. But at the base it just felt like in the US you were more likely to get a recall if you have a more marginal growth. Maybe it's just that these really small growths aren't "tumors" and my terminology is wrong? Or am I just smoking crack?