I was having an interesting Twitter chat with online friends (Liz Cohen @elizcohencnn, Dr. Chuk Onyeije @chukwumaonyeije; Dr. David Gorski @gorskon; Dr. Marya Zilberberg @murzee; Sherry Reynolds @cascadia; and @speakhealth) about the mammogram debate. They asked me “where I drew the line” on paying for expensive screening tests that may save lives but require unnecessary surgery for countless others. My opinion takes into account human nature and political savvy rather than pure science and statistics on this one.
To me, the bottom line is that the mammogram is a sloppy screening test. It’s expensive, there are lots of false positives and unnecessary surgeries, yet it saves occasional lives (which is dramatic and meaningful). We have to appreciate that women have come to accept the risks/benefits of this test, and have been told for a long time that they should begin screening at age 40.
It’s not emotionally or politically possible to reverse course on this recommendation until a better choice is available. You can trade the mammogram for a better test, but you can’t trade it for doing nothing. The amount of drama associated with the perception of having something potentially life-saving taken away is just not worth the cost savings. It may be a reasonable value judgment based on the data, but it’s not politically feasible so we should mentally take it off the table.
Instead we must focus on the search for a better test – something that’s more accurate and less expensive. We will be stuck paying for lots of unnecessary mammograms/biopsies for now, no way around it. But let’s think of it as a temporary predicament – not an eternal waste of resources.
In the end, women should have a nuanced conversation with their doctor about whether or not they are at risk for breast cancer, and make an informed personal decision about when to begin mammography screening. Guidelines are not mandates – though the USPSTF’s well intentioned report would probably have been better left unwritten.
Now let’s fund some serious research into a better screening test!