OK, I’m jumping into this controversy about screening for breast cancer (mammograms, self exams, and the under- versus over-50 issue) a week late, but not because I haven’t been following the stories. It’s kind of hard to know how to talk about one’s breasts when one has the perspectives of both an economist and a woman. Health care is like no other economic good, and breasts are like no other part of a woman.
I’ve been listening to/reading all the arguments, and I am fascinated by all the chatter on this topic from male columnists/pundits (but should I be, really?…I mean, a chance for them to think about breasts as an important “public policy” issue?), but I found Howard Kurtz’s compilation of some very varied thoughts from female commentators most enlightening (and often entertaining) and provoking of my own opinions on the issue. I am one of those women in question–over 40 but under 50–who the U.S. Preventative Services Task Force now says shouldn’t bother with routine breast cancer screening, whether via mammograms or even self exams. Their judgment is that for the broad group of “women in their 40s” who do not have genetic predisposition for breast cancer (unfortunately I do), the “benefits” of such screening don’t outweigh the “harms” (costs).
To me this is a very curious (and odd) proposition. As explained in this New York Times article by Gina Kolata, the task force’s new position basically says that more information, even if free via self exams, can be a bad thing–not because the actual gathering of that information is risky, but because of how women might react to that information (with anxiety) or choose to act on that information (with potentially unnecessary surgery, perhaps with the encouragement of their doctors). My understanding is that the health risks from the (minimal) radiation produced by mammograms is (not coincidentally) very minimal. And of course there are no health risks from the process of self-examining one’s breasts. So the task force is not saying that the process of gathering the information is risky; they’re saying that how women might choose to use that information is risky. It’s a “save me from myself” argument.
But I still don’t get it. From a pure health perspective, the potential net benefits of early detection of breast cancer–even netting out the risks associated with the various surgical and chemical treatments for the disease–can be quite large. Not gathering the information increases the likelihood of “false negatives” and disease that goes untreated, the potential cost of which is death. The argument against gathering the information for those women who have lower risk on average (the under-50 crowd) is that it increases the likelihood of “false positives” and overreacting with treatment that is unnecessary, has potential complications, and which can be drastic–for example, cutting off a breast. But the decision about whether and how to act on a positive result is a woman’s personal decision, taken under the advisement of her physician who presumably helps her evaluate her own personal physical health risks (and emotional costs as well) of treating versus not treating. I have heard stories of women with such a strong genetic predisposition to breast cancer that they opt to have double mastectomies to preempt the disease, and I assume that those women have done their own personal cost-benefit calculation and decided that they (personally) were willing to “pay” two breasts in order to guarantee they would live a full life.
My own personal story about breast cancer screening has no such drama, although I’ve had routine mammograms since age 40 and on my own had found a small lump many years ago (which has never gone away but has also never grown) and have had a needle biopsy on it that I admit wasn’t a lot of fun. But it’s always been a no brainer for me, the only issue ever being “do I have time” or “can I remember” to get my annual mammogram–not whether getting it is worth the “risk” of learning something I might act upon or the “cost” of some temporary physical discomfort from seeking even better information (via the needle biopsy). I weigh the various “costs” or unpleasantries to myself against the benefits of detection, knowing that breast cancer runs in my family, but also understanding a lot about the potential complications of the potential “next step” of treatment–including watching my mom currently dealing with the complications of what had been expected to be an uncomplicated lumpectomy. (My mom is tough though; one of her mottos has always been “deal with it.”)
But would I choose for myself to purposely not know about my lump because I’m afraid of making a dumb decision about what to do about it?…
For me, my experience during my four full-term pregnancies and deciding whether or not to have an amniocentesis to screen for Down’s syndrome was much more a case of weighing the risks of getting the information against the possible benefits of having the information. The potential health “cost” of the procedure was the small risk of premature labor or even miscarriage, but the potential “benefit” of having the information was even smaller–because had I found out my baby had Down’s syndrome it would not have changed my carrying out the pregnancy but would have only helped me prepare (psychologically and practically) for having such a baby. (Given that calculation, I never had an amnio with any of my pregnancies, but opted for less informative, but also much less risky, screening methods instead.) My decision about the screening of my own pregnancies was about very personal costs weighed against very personal benefits and not some aggregate evaluation of the cost versus benefit to someone “like” me, in my broadly-defined “risk category”.
This strikes me as a fundamental policy challenge in trying to save money by using “comparative effectiveness” research; the government can present the public with evidence that on aggregate or average some procedure is not effective enough and hence should not be supported (and by that I mean not subsidized and not not allowed), but the subset of the population for whom it is effective (no matter how narrow) will surely balk at the suggestion, and policymakers will be very reluctant to take away any kind of health benefit from anyone who actually benefits from the benefit. I’ve suggested this before: wasteful spending is in the eye of the beneficiary.
Now, it’s true that this sort of aggregate calculation of costs versus benefits has to be done if we’re going to make any progress in paring back public health spending in as “smart” a way possible, and health care subsidies by drastically reducing personal out-of-pocket costs certainly work to tilt every insured individual’s own cost-benefit analysis in favor of doing too much screening and testing. I’m just saying “good luck” coming out with the recommendations on which procedures and protocols will no longer be government recommended and subsidized without hearing from “lobbyist advocates” representing every narrow subset of people for whom the personal cost-benefit analysis doesn’t jive with the aggregate one. It’s going to be awfully hard.
Finally, while we’re on the topic of breasts, I feel like pointing out the irony of the Senate health reform bill now having a tax on elective cosmetic surgery–including “boob jobs” presumably. (Yeah, I know–it’s just another way to tax only “rich” people.) Hopefully reconstructive surgery is not considered “elective” (I haven’t read over the legislative text), but I suppose there are “grey areas”…for example, if one used to be an A cup and after “reconstruction” is a C cup, then at least some of that is obviously “elective”–and maybe some “pro-rata” portion of the cost of surgery should be taxed! (I see this as a potential tax avoidance strategy giving tax planners “more material” to work with.)
I could tell more stories and make more analogies here, but I will resist the temptation lest the additional information have negative net benefit to you readers–at least on average.