I’ve been trying to understand the flap this week over the recommendations from the U.S. Preventive Task Force - a group ill-prepared to handle the controversy - to delay routine mammograms to age 50 for most women. And now, in a truly terrible coincidence of timing, we have a second round of commotion over the advice of the American College of Obstetricians and Gynecologists to push pap smears to screen for cervical cancer back to age 21 .
The politics are irresponsible but obvious: Tie the recommendations to the boogeyman of rationing, if you oppose the White House on health care. Never mind that neither set of recommendations binds insurers or anyone else. ACOG’s pap smear advice will be “set in stone,” Sen. Tom Coburn said, and adopted without regard to differences among patients. Sarah Palin naturally piled on , suggesting that the new advice is really all about “bureaucratic pressure to control costs.”
Why do many women seem susceptible to the fear-mongering? Why is it hard to see that the costs of overscreening can outweigh the benefits of early detection?
Kevin Sack does a good job of beginning to answer these questions in the NYT this morning . The evidence about the danger of overscreening asks us to upend how we’ve long thought about risk. After years of dutiful breast self-exams and teenage pap smears, there’s a new playbook. That’s a lot to get used to, I suppose.
Also, I think, these evidence-based recommendations ask us to give up a couple of myths we hold dear. The first is that saving one life is worth any amount of trouble or money. “One life out of 1,904 to be saved,” Sen. Kay Bailey Hutchison said of the stats about getting mammograms in your 40s. Right, and the point should be, that’s not much bang for the buck . But what if it’s your life, your bang? We seem frozen on that question, unable to have the deeper discussion that should follow from it.
The second myth we’ve grown attached to is that more tests and screenings equal more control. If you get regular mammograms and pap smears, then you’re protecting yourself. It’s a kind of talisman: You won’t get cancer, or at least you won’t die of it. Cut it out early and fast! Now we have to absorb the idea that some slow-growing cancers are better left alone. We have to let go of the illusion that testing guarantees wellness and confront the far less reassuring reality that false positives lead to unnecessary interventions that can hurt us - biopsies and radiation treatment and removal of relatively harmless growths. Remember the adage that the cure can be worse than the disease? It’s unsettling. But also true.