Sebelius's cave-in on mammograms is a setback for health-care reform

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By Steven Pearlstein
Friday, November 20, 2009

Health and Human Services Secretary Kathleen Sebelius did a marvelous job this week of undermining the move toward evidence-based medicine with her hasty and cowardly disavowal of a recommendation from her department's own task force that women under 50 are probably better off not getting routine annual mammograms.

This is an old issue that has not only sharply divided the medical community for more than 20 years, but also taps into deep resentments among women who, over the years, have felt neglected by a male-dominated medical establishment. And there's no doubt that the advisory panel's recommendation came at a politically inconvenient time, just as Congress enters the crucial final phase in a health reform debate in which opponents have successfully stoked fears of medical rationing.

But rather than showing the leadership necessary to lead a grown-up national discussion on how to eliminate unnecessary or wasteful procedures, Sebelius simply disowned the task force and ran for political cover. Just as the hysteria over "death panels" killed any chance that Medicare recipients and their patients might be encouraged to engage in an intelligent conversation about end-of-life care before it becomes an issue, the mammogram brouhaha is likely to set back efforts to dramatically increase research into what really works and what doesn't, and use the results to revamp the way medical care is delivered and paid for.

I should acknowledge that I have no idea who should and should not get routine mammograms. But I know enough about statistics to say that the issue is not settled just because you know of someone in her 40s whose breast cancer was detected by a mammogram and cured. As economists and medical researchers are fond of saying, the plural of anecdote is data.

To make a valid scientific finding of who should be screened and how often, you'd have to take into consideration how big the risk is that women are likely to develop cancer at any particular age; how fast tumors are likely to grow and how likely they are to be cured once they are caught; what is the likelihood that a tumor detected by mammogram might be found some other way; what is the probability that a suspected tumor turns out not to be pre-cancerous, or that doing a biopsy on it will actually increase the chance that it could become dangerous later. You'd also have to weigh the benefits of routine screening -- deaths avoided and years of life extended -- against the medical problems caused by complications that arise from biopsies, along with the mental anguish that goes along with the large number of false positives that crop up on mammographies of women in their 40s.

All that, of course, is exactly what the task force did, based on numerous studies done in different countries using different methodologies. In the end, it found that while some lives might be saved each year, the benefits of annual screening of women in their 40s were outweighed by the costs -- and that's without even getting into the financial costs, which run to several billion dollars a year.

As is often the case in such matters, those raising the most fuss were those with greatest financial interest in mammography (the radiologists and the makers of mammography machines) and the disease groups (in this case, the American Cancer Society), which tend to resist recognizing limits on how much time, money and attention is devoted to their cause.

"How many mothers, sisters, aunts, grandmothers, daughters and friends are we willing to lose to breast cancer while the debate goes on about the limitations of mammography?" Otis Brawley, chief medical officer of the American Cancer Society, asked in an op-ed article in Thursday's Washington Post. Dr. Brawley cleverly didn't answer his own question, but the clear implication of his question was that the only acceptable number should be zero. And it is that very attitude, applied across the board to every patient and every disease, which goes a long way in explaining why ours is the most expensive, and one of the least effective, health-care systems in the industrialized world.

The political argument from the White House was that it was necessary to duck this fight over evidence-based medicine in order to save it. The better approach would have been to see this as one of those teachable moments that could be used to reaffirm the entire rationale for reform. For while debate continues over whether some women may be getting too many mammograms, there is evidence that there are women who, because they lack insurance, are getting too few -- and dying unnecessarily as a result. What health reform is about is correcting that imbalance while devising new mechanisms for improving health outcomes and getting better control over costs.

Put in that context, it would have been perfectly reasonable for Sebelius to have announced that she was delaying implementation of the task force recommendation for a year in order to give it more time to seek a broader consensus among researchers, doctors and patients. That would have made clear that the administration remained committed to a health-care system driven by the best medical evidence but one that is also sensitive to broad public opinion. This is a tough-love message the country, and the Congress, need to hear.

As in the past, I'm preparing a holiday column highlighting extraordinary examples of corporate philanthropy during the past year. If you know of examples of companies and their employees that have gone above and beyond this year in providing time and money to a nonprofit, drop me an e-mail at pearlsteins@washpost.com. Include the relevant details, along with a name and phone number of someone to contact. And be sure to write the words "Holiday Column" in the subject line. Deadline for submissions is Dec. 11. Thanks.


© 2009 The Washington Post Company

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