Fierce debate raging over new cancer test guidelines

Nancy-Ann DeParle, director of the Office for Health Reform, said the debate goes to the heart of the doctor-patient relationship.
Nancy-Ann DeParle, director of the Office for Health Reform, said the debate goes to the heart of the doctor-patient relationship. (Bill O'leary/the Washington Post)
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By Rob Stein
Washington Post Staff Writer
Sunday, November 22, 2009

President Obama's vision for making health care in America more effective and efficient collided for the first time last week with the realities and peculiarities of the nation's health-care system.

As the Senate moved toward its first floor vote on the health-care reform bill, two independent expert groups coincidentally released new guidelines for mammograms and Pap tests aimed at improving treatment for two forms of cancer in women.

Although neither set of recommendations was aimed at cutting costs, both were based on the kind of objective analysis of scientific research that the Obama administration has embraced in its bid to make care better and more economical.

But after the recommendations unleashed fierce criticism, controversy and debate, the administration appeared to quickly distance itself from the mammography guidelines to try to prevent the uproar from endangering a domestic priority.

"This tells us an awful lot more about where we are as a country in terms of our relationship to the health-care system and health-care reform than they do provide new information about how often women should get screened," said John Abramson, a clinical instructor at Harvard Medical School and a leading proponent of eliminating unnecessary care. "It's like a Rorschach test of where we are when it comes to the health-care system and health-care reform."

Nancy-Ann DeParle, director of the White House Office for Health Reform, said Saturday that the debate over the guidelines goes to the heart of "the unique doctor-patient relationship in the American health-care system and the desire to preserve that."

"Today many of these decisions are being made by insurance companies and bureaucrats, and we want to make sure those decisions are made by doctors," DeParle said.

'Evidence-based' care

The recommendations about mammograms and Pap tests are the latest in a series of guidelines that have been emerging as part of "evidence-based" medicine. The seemingly obvious idea behind the movement is to base medical decisions on the best available scientific evidence, including "comparative effectiveness" studies, instead of relying on tradition, intuition or personal experience.

"One of the things I think you're seeing is the maturation of the concept of evidence-based medicine," said Ned Calonge, chairman of the U.S. Preventive Services Task Force, the federally appointed panel that issued the new mammography guidelines.

That task force and others had begun backing off recommendations that men routinely undergo PSA testing for prostate cancer. That rethinking was based on a similar argument: that although the tests may save lives, they often produce false alarms that cause unnecessary anxiety and find tumors that may never require treatment but nonetheless prompt men to get surgery, chemotherapy or radiation, which can leave them impotent and incontinent.

Those recommendations, although somewhat less controversial than the new mammography guidelines, remain the subject of debate. One large study released in March estimated that to prevent one prostate cancer death, more than 1,400 men would need to get PSA tests and 48 would need to be treated. Proponents, however, say the evidence questioning the test's power to prevent deaths is flawed.

In the case of mammography, which costs the nation about $5 billion annually, the task force concluded that although screening reduces the number of women who die from breast cancer, annual screening starting at age 40 rather than 50 comes with a huge downside: For every woman whose life is saved, many more suffer through the erroneous fear that they have cancer, get exposed to radiation from more tests, undergo biopsies, and often endure surgery, radiation and chemotherapy for tumors that may never be life-threatening.

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