[I started working on this last night and ran out of steam -- I then awoke to a front page New York Times story dealing with new recommendations on cervical cancer screening-- this is going to take a lot of people's paranoia level up to eleven, not to mention the full-on wingnut exploitation sure to follow.]
It was interesting to see the reaction to the recommendations of the U.S. Preventive Services Task Force regarding breast cancer screening. In a nutshell, the study cast doubt on the efficacy of annual mammograms for women between the ages of 40 and 50 who are not at an elevated risk for breast cancer. The study concluded that routine annual screening in this age group was not cost effective and should be deferred until women reached the age of 50. The study found that mammography did result in lives saved, but weighed this unfavorably against the cost of such widespread screening, the psychological stress associated with the numerous false positives in the tests, and the unnecessary biopsies and other procedures resulting from those false positives.
This conclusion prompted genuine outrage in many circles, some of the opportunistic and political variety (yes, I am looking at you Republicans), but much from people who strongly feel that this is bad advice that reflects a warped sense of cost and benefits. The reaction has been especially strong in segments of the women's community, where it seems to be viewed as trivialization of women's health and lives. (I was laughing at one commenter who claimed that they would never do this with prostate cancer, but as I discuss below, exactly that sort of recommendation has come out regarding certain prostate cancer screening.) The authors of the recommendation appear baffled by the firestorm that has greeted their recommendation. The people who do this kind of work are generally doctors and nurses with either masters in public health or PhDs. They are not typically front line practitioners, but rather study reviewers and number crunchers. Their approach to these issues is a dispassionate statistical analysis that looks at overall outcomes and costs and weighs them in a way that may strike many as cold and even inhuman. I understand that reaction -- my layman's limited scrutiny of the study left me with the feeling that the call was closer than the Task Force let on.
Interestingly, a similar study for screening for prostate cancer did not generate nearly as much attention. Part of that seems to me to be an accident of timing -- health care reform is clearly the subtext to this, even if the studies' releases are coincidental. Not to engage in gender essentialism, but I think this may have to do with the fact that men are always comfortable with a recommendation that reinforces our tendency toward denial in these kinds of matters -- oh the test is no good -- great, I'll skip it. (Or maybe I'm just projecting.)
I do think the people who are upset with the studies need to take a deep breath and look at all of them anew. They tell us a couple of things that are worth noting, even if you ultimately conclude that personally you are going to get all of the screening you can. The first and most obvious -- and in some ways the least persuasive to many people -- is that all of this screening is really expensive. Really expensive. And raises the obvious question of whether our health care dollars could be more effectively deployed. [In the case of pap smears for women under 21, doctors detect one to two cases of cervical cancer per one million 15 to 19-year old girls screened.] But the bigger point to me is that the results of these tests are not always (please forgive the pun) so benign. People are not only put through a great deal of stress due to erroneous readings of these results, which I suppose we can live with, but are subject to additional invasive tests -- biopsies, fine needle aspirations, and actual treatment for cancers that may not be a danger to them.
Ultimately though, I think the largest point is that all of our emphasis on screening, prevention, and early treatment are to some degree faith-based talismans, ways to ward off our understandable fears. The reality is that our tools in screening for many kinds of cancer remain relatively crude despite their great expense and they cannot prevent the disease from occurring. In the end, we continue to confront our own vulnerability and mortality, things that can't be tested away.
I have added this link, at Jim Benton's recommendation, to an excellent blog post by a real doctor rather than a juris doctor on this issue.
