It was nearly two years ago that I wrote this about the controversy over mammogram screenings for breast cancer:
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.
I went on to tell a couple of my own stories related to the question “is testing worth it?” Now we have the same group saying that maybe men shouldn’t have PSA screenings for prostate cancer done. From the Washington Post’s story:
Most men should not routinely get a widely used blood test to check for prostate cancer because the exam does not save lives and leads to too much unnecessary anxiety, surgery and complications, a federal task force has concluded.
The U.S. Preventive Services Task Force, which triggered a firestorm of controversy in 2009 when it raised questions about routine mammography for breast cancer, will propose downgrading its recommendations for prostate-specific antigen (PSA) for prostate cancer onTuesday, wading into what is perhaps the most contentious and important issue in men’s health.
Task force chairwoman Virginia Moyer said the group based its draft recommendations on an exhaustive review of the latest scientific evidence, which concluded that even for younger men, the risks appeared to outweigh the benefits for those who are showing no signs of the disease.
“The harms studies showed that significant numbers of men — on the order of 20 to 30 percent — have very significant harms,” Moyer, a professor of pediatrics at Baylor College of Medicine, said in a telephone interview Thursday.
The “significant harms” in the guys’ case? Again, from the Post account (emphasis added):
Because it is not clear precisely what PSA level signals the presence of cancer, many men experience stressful false alarms that lead to unnecessary surgical biopsies to make a definitive diagnosis, which can be painful and in rare cases can cause serious complications.
Even when the test picks up a real cancer, doctors are uncertain what, if anything, men should do about it. Many men are simply monitored closely to see whether the tumor shows signs of growing or spreading. Others undergo surgery, radiation and hormone treatments, which often leave them incontinent, impotent and experiencing other complications.
Seems pretty analogous to the case against mammograms for women. And I think the same issues I raised on the mammograms apply here: I’m not sure I buy the “save me from myself, as I might freak out” attitude. The point is that the test does pick up a “real cancer” at least occasionally. So there has to be an individual weighing of expected benefits from the test versus expected costs. The PSA test is going to more likely pass the (expected) cost-benefit analysis when factors such as genetic predisposition (higher potential benefit from screening, in avoiding death) and age (lower potential cost from screening if one is younger and otherwise not so vulnerable to complications from surgery) work in its favor. But that cost-benefit analysis is a very individual thing. To suggest with blanket recommendations that the test might not be such a good idea because it just has those potential costs (regardless of the potential benefits) to me seems very dangerous. People don’t need another reason to avoid medical tests, in my opinion. There’s already a magnifying of the (even psychic) “costs” of getting tested relative to the potential benefits. And at least some people will surely die from the cancer if they never find out it’s there until it’s too late.
What’s different about the guys’ case? I find it kind of interesting that the women may overreact by cutting off their breasts, while the men may overreact and get the kinds of treatments that can leave them impotent. Hmmm…. does this mean people would rather die than (potentially) not have (as much) sex?
Not entirely joking here. Just wondering out loud.
(UPDATE, 1 pm: This article, coming out in this Sunday’s New York Times Magazine, is very good at elaborating on the benefits vs. costs of the PSA test.)