As December is upon us and stores fill with the reminder that yet another holiday season is upon us, we think of another fast approaching anniversary. In December 2009 the USPSTF’s release of new suggested mammography guidelines. A strange event to commemorate you might think, but one that is very important in the world of breast cancer advocates and health care providers. Just this morning, another study was released to throw a wrench in the gears of this ever increasing confusion. A study presented at the annual meeting of the Radiological Society of North America (RSNA) shows a decrease in mastectomy rates for women undergoing yearly mammography. A report on the study can be seen here: http://tinyurl.com/39cfckc
Health reporters have already jumped on the assumption that this means the cancer is caught earlier and thus it would seem natural to assume that an earlier diagnosis changes long term survival rates, this too is a source of controversy. One that makes us all very nervous and probably not for the reasons you would guess.
The new guidelines created a ripple felt around the country as we had a dialogue about needed healthcare reforms and improving preventative medicine. The new guidelines called into question the need for every woman to have yearly mammogram after the age of 40. Immediately, a divide was created, but not necessarily amongst the groups you might think. It was not just the ones who pay for mammograms vs. the ones who receive them. Breast cancer advocacy groups themselves took divisive stances on the issue. Some site the need to stick by available research that does not clearly indicate a benefit to yearly mammography in the age 40-50 age group, some yelling back that the research has major holes and does not clearly reflect all the benefits to of catching cancer earlier. We have put all our eggs in the basket of whether early detection saves lives in the long run, but is that enough? We have not established a good measure for quality of life (yes, I may live longer, but what if I am too tired to play with my kids?) We do not have a good reporting system for levels of treatment (what if early detection allowed me to have a lumpectomy rather than a mastectomy?) We also don’t have a good reporting method for longevity. Most cancer research is based on the 5-year survival mark, but it has become increasingly difficult to follow-up with survivors after that mark and most funding sources for this research don’t support this level of long-term tracking.
From a cancer survivor’s perspective, this has to be about more than just a yearly mammogram, it has to be about the big picture. It has to be about women’s health and a consistent relationship with her healthcare providers. If we are not tracking the effect of early detection on the whole picture of a woman’s outcome are we really serving her interests? Are we improving healthcare in this country? The bigger danger to not screening women yearly with mammograms is not really about finding lumps, its about giving women a reason to be checked out yearly by a healthcare provider. I know, I know, a blasphemous statement. How can we use mammography with all its false positives and inaccurate technology as an excuse to get women seen by a doctor every year? Simply put... the woman in her 40’s is an a unique window where she, by default, would not be seen yearly by a healthcare provider otherwise. She is too young for colonoscopy (age 50). She is usually too old for childbearing issues. If she is not high risk, she only needs a pap smear every 3 years. In many ways she is at the prime of her life, so why go see a doctor if she isn’t sick? This isn’t even an access issue, as many groups like to claim. The fastest growing demographic of women who are not undergoing regular screening is not poor women in remote areas, as its been portrayed. Its actually well-educated, insured women who just don’t make it a priority. We can’t afford to take a step back in women’s health by giving them one more excuse to avoid a regular visit with a healthcare provider.
Do we really understand what a, “cure” to cancer really looks like? Is a cure about treating cancer into complete remission once it is found, or is a cure an absolute prevention from it developing to begin with? Many people often site polio as a disease we have been successful at curing, but what we have really done is just found a really great way to prevent it, not to treat it absolutely if it develops. “Mammograms save lives” really is an incorrect statement, because a mammogram itself does not save lives. It is how the healthcare providers in the country respond to the outcome of that mammogram that saves lives. It is the prevention of the need for that mammogram in the first place, that saves lives. We need to stop trying to separate each individual test, vaccine and screening tool into its own separate island and look at these issues as the village that keeps the individual strong and thriving. It is not a popular theory, but a necessary one if we are really serious about raising the level of healthcare in the United States.
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