Culture Clash in Medicine
By KEVIN SACK
This week, the science of medicine bumped up against the foundations of American medical consumerism: that more is better, that saving a life is worth any sacrifice, that health care is a birthright.
Two new recommendations, calling for delaying the start and reducing the frequency of screening for breast and cervical cancer, have been met with anger and confusion from some corners, not to mention a measure of political posturing.
The backers of science-driven medicine, with its dual focus on risks and benefits, have cheered the elevation of data in the setting of standards. But many patients — and organizations of doctors and disease specialists — find themselves unready to accept the counterintuitive notion that more testing can be bad for your health.
“People are being asked to think differently about risk,” said Sheila M. Rothman, a professor of public health at Columbia University. “The public state of mind right now is that they’re frightened that evidence-based medicine is going to be equated with rationing. They don’t see it in a scientific perspective.”
For decades, the medical establishment, the government and the news media have preached the mantra of early detection, spending untold millions of dollars to spread the word. Now, the hypothesis that screening is vital to health and longevity is being turned on its head, with researchers asserting that mammograms and Pap smears can cause more harm than good for women of certain ages.
On Monday, the United States Preventive Services Task Force, a federally appointed advisory panel, recommended that most women delay the start of routine mammograms until they are 50, rather than 40, as the group suggested in 2002. It also recommended that women receive the test every two years rather than annually, and that physicians not train women to perform breast self-examination.
The task force, whose recommendations are not binding on insurers or physicians, concluded after surveying the latest research that the risks caused by over-diagnosis, anxiety, false-positive test results and excess biopsies outweighed the benefits of screening for women in their 40s. It found that one cancer death is prevented for every 1,904 women ages 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women from 50 to 74, and one death for every 377 women from 60 to 69.
On Friday, the American College of Obstetricians and Gynecologists plans to announce a similar revision to its screening guidelines for cervical cancer. It will advise that women receive their first Pap test at age 21; the previous standard had been three years after a woman’s first sexual intercourse or age 21, whichever came first. The group also is recommending that the test be performed every two years instead of annually for women ages 21 to 30.
“A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs and avoids unnecessary interventions that could be harmful,” said Dr. Alan G. Waxman, a professor at the University of New Mexico who directed the process.
The challenge of persuading patients and doctors to accept such standards requires a transformational shift in thinking, particularly when the disease involved is as prevalent, as deadly, and as potentially curable as cancer. How do you convince them that it is in their best interest to play the odds when they have been conditioned for so long to not gamble on health? After all, for the one in 1,904 women in their 40s whose life would be saved by early detection of breast cancer, taking the risk would in retrospect seem a bad choice.
“This represents a broader understanding that the efforts to detect cancer early can be a two-edged sword,” said Dr. H. Gilbert Welch, a professor of medicine at Dartmouth who is among the pioneers of research into the negative effects of early detection. “Yes, it helps some people, but it harms others.”
Dr. Welch said this week’s recommendations could mark a turning point in public acceptance of that notion. “Now we’re trying to negotiate that balance,” he said. “There’s no right answer, but I can tell you that the right answer is not always to start earlier, look harder and look more frequently.”
That concept is proving easier to swallow in the halls of Dartmouth Medical School than in the halls of Congress. Coming as they did at the height of debate over a sweeping health care overhaul, the recommendations have provided fresh ammunition for those who warn that greater government involvement in medical decision-making would lead to rationing of health care. It has not mattered that the breast cancer screening recommendation is only advisory, and that the federal government, the American Cancer Society, and numerous private insurers have said they will not adopt it.
Senator Kay Bailey Hutchison, a Republican who is running for governor of Texas, cited the task force’s screening statistics in a floor speech on Thursday. “One life out of 1,904 to be saved,” Ms. Hutchison said, “but the choice is not going to be yours. It’s going to be someone else that has never met you, that does not know family history.” She added, “This is not the American way of looking at our health care coverage.”
The health care bills in both the House and the Senate would establish commissions to encourage research into the effectiveness of medical tests and procedures, but would not require that the findings be translated into practice or reimbursement policies.
As throughout history, it may take decades for medical culture to catch up to medical science. Dr. Rothman pointed out that it took 20 years for the public to accept the discovery in 1882 that tuberculosis was caused by a bacterium and not by heredity or behavior. More than 160 years after the Hungarian-born physician Ignaz Semmelweis posited that hand-washing could prevent the spread of infectious disease, studies still show that half of all hospital workers do not follow basic hygiene protocols.
“It’s going to take time, there’s no doubt about it,” said Louise B. Russell, a research professor at the Rutgers University Institute of Health who has studied whether prevention necessarily saves money (and found it does not always do so). “It’s going to take time in part because too many people in this country have had a health insurer say no, and it’s not for a good reason. So they’re not used to having a group come out and say we ought to do less, and it’s because it’s best for you.” |
