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With mammograms, listen to the experts

By John W. Rowe M.D., Special to CNN
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STORY HIGHLIGHTS
  • John Rowe says new mammogram report shows tension between scientific analysis, "rationing" fears
  • He says independent analysis should guide care standards
  • Targeting those with higher cancer risk avoids bad consequences for those at low risk, Rowe says
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Editor's note: John Rowe M.D. is a professor in the Mailman School of Public Health at Columbia University. He previously served as president and CEO of the Mount Sinai Medical Center in New York City and as Chairman and CEO of Aetna, Inc.

New York (CNN) -- The new recommendations for breast cancer screening -- and the public debate surrounding them -- underscore the need to distinguish between rationing and establishing science-based standards of health care. That distinction will be crucial as we strive for better and more affordable care in the United States.

The U.S. Preventive Services Task Force, which made the recommendations, reviewed new scientific studies and concluded that for women in their 40s, when the likelihood of breast cancer is very low, routine screening is not necessary and that, thereafter, mammography at two-year intervals provides essentially the same benefit as annual tests.

These recommendations have been greeted with understandable skepticism and claims of "rationing."

After all, in the midst of the current health care reform debate it is easy to question the motives of a group seen by some as "government-sponsored," and new science-based recommendations for less, rather than more, care often meet populist resistance.

Years ago, for instance, some advocates were convinced, despite the absence of scientific evidence, that bone marrow transplants could save patients with breast cancer. They were so sure that they resisted the use of randomized controlled trials -- the gold standard of clinical research -- on the grounds that the randomization of patients, some of whom received a placebo (non-transplant), was unethical as it withheld presumed life-saving treatment.

Eventually the proper studies were conducted, demonstrating that bone marrow transplant offered no net benefit and actually increased mortality. The procedure has since disappeared from American medicine.

As science evolves, we need an independent and expert group, such as the U.S. Preventive Services Task Force, to objectively evaluate new scientific evidence and guide the establishment of standards of care. Otherwise, care will be based on the biases of our individual experience.

In my case, that experience includes multiple, even conflicting, biases. My mother had breast cancer twice, and I have three daughters. I previously served as the CEO of a large academic medical center, where I supervised a profitable Department of Radiology that conducted and interpreted thousands of mammograms. And I later served as the CEO of a health insurance company that paid for such tests.

The charge of rationing -- a dirty word in American medical politics -- has polarized the debate. In health care, rationing refers to restricting the consumption of a relatively scarce resource, such as setting priorities for patients most suitable for heart or lung transplants, which are in very short supply.

Mammograms are not in short supply. The current debate is not about rationing, but about the establishment of science-based standards in screening for cancer.

A key myth in this context is that screening is harmless. On the surface, the myth seems reasonable: What could be harmful about screening? But we now know that screening is not innocuous. For instance, repeated exposure to the ionizing radiation of CT scans in screening for lung cancer or heart disease may substantially increase the risk of cancer. In the case of mammograms, the downside is not cancer but still very real.

Mammograms are not perfect, and it is common for the test to suggest the presence of a tumor when one does not exist. Such "false positives" lead to repeat mammograms in 1 in 10 women, surgical biopsies in 1 in 100, and a significant burden of sleepless nights, as well as occasional surgical complications such as infection.

Despite these facts, it makes perfect sense that most women would rather have a potentially lethal and treatable cancer detected early than forego a test in order to avoid the risk of a false positive. One could even ask why we have not heard calls for screening between ages 30 and 40, or between 20 and 30. After all, the risk of cancer in those decades, while very very low, is not zero.

Our health care system is often referred to as "broken". We conduct too many procedures and write too many prescriptions for little benefit. If we, as a nation, are to afford the new effective tests and treatments that become available each year, we need to reduce expenditures on those treatments and tests that add little, if any value.

The scientific evidence is now clear: Mammograms in 40-50-year-old women, and annual testing thereafter, are such very low-value procedures. We can now target screening to those at higher risk of cancer and decrease the negative consequences of screening for those at very low risk.

The path to a rational health care system requires a transition from a system in which every patient gets everything all the time to one in which we give the right treatment to the right patient at the right time. Understanding the difference between establishing valid standards of care and rationing is a key step in that transition.

The opinions expressed in this commentary are solely those of John Rowe.