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Komen’s accidental case against breast exams

By Ezra Klein,

It will be years until we know how the Komen/Planned Parenthood fight really ended. The Susan G. Komen Foundation has apologized, and promised to allow Planned Parenthood to apply for grants in the future, but they haven’t said whether they will fund them.

That’s really what matters here, and it’s entirely possible that, two years from now, when the cameras are off, almost every Planned Parenthood grant request will be denied. Which gets to one of the weirder wrinkles in this debate: The argument, made by Komen, that mammography counts as a cancer prevention service, but clinical breast exams don’t. If Komen sticks to that position, it could be a reason for them to refuse future grant applications from Planned Parenthood. But it would be a strange reason, given that Komen’s Web site currently recommends clinical breast exams for all women over 20.

Michael Goulding

Associated Press

Doves are released during the Survivor Tribute at the 20th annual Susan G. Komen Race for the Cure Orange County on Sunday, Sept. 25, 2011 in Irvine, Calif.

Originally, Komen said Planned Parenthood was ineligible for grants because they were under congressional investigation. But they quickly abandoned that claim and moved to a more apolitical explanation: Planned Parenthood doesn’t directly provide mammography. “We have decided not to fund, wherever possible, pass-through grants,” said Nancy Brinker, president of the Susan G. Komen Foundation. “We were giving them money, they were sending women out for mammograms.”

It’s worth stepping back to explain what’s going on here. A mammogram is low-energy x-ray of the breast. They are recommended on an annual or semi-annual basis for women over 40, though recent research has suggested that they should only be recommended for women over 50, and only semi-annually.

Women younger than 40 — or, potentially, 50 — are advised to get clinical breast exams on an annual or semi-annual basis. The American Cancer Society, for instance, recommends clinical breast exams at least every three years for women under 40, and every year for women over 40. The National Cancer Institute agrees, and says “getting a high-quality screening mammogram and having a clinical breast exam (an exam done by a health care provider) on a regular basis are the most effective ways to detect breast cancer early,” because “some cancers cannot be detected by a screening mammogram but may be found by a clinical breast exam.”

Planned Parenthood acts as a sort of primary care doctor in this process: You go to them, and they tell you what to do next. “Planned Parenthood offers breast exams at every one of our family planning health centers,” says Tait Sye, a spokesman for Planned Parenthood. “And like the vast majority of primary care physicians and ob-gyns, we refer our patients to other facilities for mammograms when indicated based on a breast exam, age or family history. Last year, we provided nearly 750,000 breast exams.”

One argument for Planned Parenthood’s role is that many women don’t have a primary care doctor, and don’t know where they need to go for a mammogram, or even that they need to go for a mammogram. Planned Parenthood, which often has a long-standing relationship with poorer women whose attachment to the health care system is more marginal, helps set them up with whatever cancer screenings are most appropriate for them.

The argument against that role is that the research on breast screenings is even more ambivalent than the research on mammography. The Centers for Disease Control, for instance, warn that “a clinical breast exam or a breast self-exam have not been found to decrease risk of dying from breast cancer.”

If Komen had initially argued that they would no longer fund organizations that didn’t directly provide mammograms, they would, perhaps, have had an easier time explaining their decision. Of course, that might have meant defunding a much larger swath of organizations. It also would have meant changing their recommendations to women.

Komen declined to comment for this piece. But their Web site has a section on clinical breast exams: “Starting at age 20, CBE is part of routine breast cancer screening for women. When you begin having mammograms, CBE complement these screenings.” Given this, it seems unlikely that Komen really meant to take a stand against clinical breast exams.

The likelier explanation, as Kate Sheppard has persuasively argued, is that the shifting rationales behind Komen’s decision imply that the decision to defund Planned Parenthood was based on either political or ideological considerations regarding abortion. But because many of Komen’s funders are pro-choice, it couldn’t be described that way. Hence the hunt for alternative justifications, and the eventual apology and putative reversal.

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