Hurt or Heal? The Importance of Weighing the Evidence in Medical Care and Coverage
Let's face it. We are spoiled. We have over 1,000 television channels to choose from and still can't find anything worth watching. We have dozens of toilet paper brands to choose from. Do we want it softer or stronger? Or extra soft. We have been taught the more choices the better and we sulk if our favorite brand of cereal isn't on the shelf, even though there are dozens more to try. And we expect these consumerist attitudes to translate into medical care.
Medical lingo has even changed to accommodate this new market mentality. People who seek medical care are no longer patients, they are 'consumers.' We seek medical care from 'providers,' not doctors and hospitals. We want to 'compare' treatments, like we would television sets. But even when comparing manufactured goods we often want help deciding what we should choose. We can get help from entities like Consumers Union, who methodically and scientifically test products and tell us which ones wear out faster, which ones clean better, which ones capture color best.
But if we are unhappy with our choice in refrigerators, it is not life threatening. Our choice of medical treatment could be. So why all the controversy over an apolitical group of medical professionals examining the clinical evidence and changing their recommendations for breast cancer screening?
Politics aside, don't we want doctors and other medical professionals to have a team of experts reviewing the data and making evidence-based recommendations they can use when giving us, their patients, advice?
Let's face facts. No doctor, no matter how good, intelligent or dedicated, has the time or expertise to review all the evidence in every type of treatment and come to his or her own conclusions. And medicine evolves.
Take the treatment of ulcers. For decades stomach ulcers were believed to be caused entirely by emotional stress. In 1982 a physician in Australia, Barry Marshall, noticed that biopsies (little bits of tissue) obtained from the stomach lining of patients suffering from ulcers had a previously unidentified bacterium. His theory hit the wall of the medical establishment, which scorned his reasoning:
"Practitioners of gastroenterology and the pharmaceutical industry were both heavily invested in the theory that peptic ulcers were caused by emotional stress and stomach acids, and could only be treated with repeated courses of antacid medication. While the reduction of stomach acid often alleviated the existing ulcer, inflammation of the stomach lining usually persisted, and most patients found themselves returning in a year or two with another ulcer. Patients were routinely advised to seek psychiatric counseling, find less demanding employment or make other drastic lifestyle changes to address the purported cause of their disease. Volumes were published detailing the alleged psychological causes of gastric ailments, and ulcers remained a frequently cited example of psychosomatic illness."
It took a decade before his theory was widely accepted as fact and treatment protocols changed. In 2005, Dr. Marshall and his colleague were awarded the Nobel Prize in Physiology or Medicine for their discovery of the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease:
"Even though peptic ulcers could be healed by inhibiting gastric acid production, they frequently relapsed, since bacteria and chronic inflammation of the stomach remained. In treatment studies, Marshall and Warren as well as others showed that patients could be cured from their peptic ulcer disease only when the bacteria were eradicated from the stomach. Thanks to the pioneering discovery by Marshall and Warren, peptic ulcer disease is no longer a chronic, frequently disabling condition, but a disease that can be cured by a short regimen of antibiotics and acid secretion inhibitors."
That is what looking at the evidence can achieve. That is what we want from our medical care: better, more effective treatments.
Unfortunately, the facts are not always so clear cut. In many cases, the experts must weight the potential positive and negative consequences of a medical intervention. That is the case with the mammography recommendations.
What could be wrong with trying to catch breast cancer as early as possible in as many women as possible? The importance of early detection has been so droned into us, it is no wonder people are angry and confused when new recommendations seem to go against that 'common sense' idea. We have to remember that any medical intervention can have negative consequences. Here is one potential negative side effect of mammographies I have not seen widely discussed in this controversy:
"Radiation causes 1 death for every 2,000 women screened annually starting at age 40, according to a study published in 2005 in the British Journal of Cancer. Another study shows that each mammogram increases the risk of breast cancer by 2 percent. Mammography also saves women's lives, so that's why it's a trade-off."
With such a large threat looming it is important that the benefit of the intervention overshadow it. But it doesn't in mammographies for women under 50:
"You need to screen 1,900 women in their 40s for 10 years in order to prevent one death from breast cancer, and in the process you will have generated more than 1,000 false-positive screens and all the overtreatment they entail. This doesn't make sense. We could do more research and hold more consensus conferences. I suspect it would confirm the data we already have. But history suggests it would never be enough to convince many people that we are screening too much."
Finally, let's get the facts straight on all fronts. The Senate health reform bill does not mandate that all insurance companies cover only what the U.S. Preventive Services Task Force recommends. It only requires insurance companies cover, at no cost to the patient, the preventive care recommended by the Task Force:
"SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES. (a) IN GENERAL. — A group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide coverage for and shall not impose any cost sharing requirements for — ''(1) evidence-based items or services that have in effect a rating of 'A' or 'B' in the current recommendations of the United States Preventive Services Task Force."
This is great health policy because preventive care is important to maintain health and thus keep long-term care costs down, and because evidence suggests people are more likely to get recommended preventive care if they do not have to pay out of pocket for it. For example, a study published in the January 24, 2008 issue of the New England Journal of Medicine found that a co-pay as small as $10 can keep a woman getting a mammogram. The study's author recommended exactly what the Senate health reform bill does:
"For highly valuable services, such as mammography, insurers should eliminate co-pays. It could save lives. And, a small co-pay doesn't make a lot of economic sense if it deters women from getting timely screenings. The costs of untreated early disease are much higher."
The only difference is that the U.S. Preventive Services Task Force now believes mammographies are generally 'highly valuable' for women over 50, not those between 40 and 50.
In the end, however, we should all keep in mind what NBC's Dr. Nancy Snyderman, emphasized:
"It's important to remember that these new recommendations from this independent task force are just that — they're recommendations. They don't mandate any changes in who should get mammograms and when."
Next entry: The Fight For Health Care Reform Must Continue