You’re a woman in your 40s—should you or should you not get a mammogram? The recent firestorm over guidelines released last month by the U.S. Preventive Services Task Force has not made the decision any easier. No sooner had the independent panel of experts published its recommendation against routine screening for women in their 40s, than everybody from Secretary of Health and Human Services Sebelius to doctor groups to the American Cancer Society was trying to throw the task force and its guidelines under the bus. Even the Senate got into the act earlier this month when it voted to approve an amendment to the health bill, barring the federal government from using the task force’s guidelines to deny coverage of mammograms for women in their forties.
Yet a careful reading of the guidelines says something quite different from the position that has caused such a flap. What the task force said was not that women should not get mammograms, but rather that the decision should be made on a case-by-case basis, accounting for a patient's history and values regarding specific benefits and harms. In other words, it should be a shared decision between the individual patient and her physician.
That might sound like a cop-out on the part of the task force, but it’s a sensible position for a screening test that can lead to both positive and negative results. Patients facing any elective treatment, including cancer screening tests, deserve a chance to understand the possible risks and benefits for themselves, and to share the decision with their doctors. In the case of mammography, the vast majority of women are quite capable, given the information in a form that’s digestible, of grasping the tradeoffs involved and making a decision that’s right for them. The idea that such decisions should be shared by patients and doctors, rather than dictated by experts or patients' advocacy groups or members of Congress is also embodied in provisions in both the Senate and House health care bills.
What are the tradeoffs of mamography? Most already know the potential benefit of early detection, but the downsides of mammography are often poorly understood by both patients and physicians. First there’s the radiation. For younger women, each dose of radiation in a mammogram slightly increases her risk of developing a tumor down the road, and the more mammograms received, the higher the risk of developing a tumor later. Then there are the false positives – a mammogram that says there’s a tumor when there isn’t. About one in 10 women undergoing regular mammography in their 40s will have a false positive that requires more testing, including biopsies. For every woman in her 40s who has an actual tumor, five women must undergo a biopsy for a false positive.
False positives are not even the most serious drawback. Women – and doctors – often think that it’s better to be safe than sorry when it comes to detecting and treating breast tumors, but mammograms can also lead to surgery, chemotherapy, or radiation for a tumor that did not need to be treated. For every 10 women who are diagnosed with early stage breast cancer, as many as three will be treated unnecessarily for a tumor that was so slow growing it might never have bothered the women in their lifetimes, or it could have been detected and successfully treated at a later date. That means that some women will die each year from being treated for a tumor that would not have harmed them.
That’s why patients deserve the opportunity to understand the tradeoffs and decide for themselves. Both the House and Senate health care reform bills contain provisions that would promote shared decision making and the use of “patient decision aids,” booklets, interactive web-based programs, and videos that walk patients through the pros and cons of mammograms in their 40s as well as many other health choices.
In the case of mammograms, most women need some help sorting through the statistics in order to weigh the competing risks – help that doctors are not always equipped to provide. Physicians are not well-trained to explain complex information, and their own opinions can get in the way of helping a woman understand her options. Good patient decision aids offer balanced information on treatment choices. Once a woman has been presented with all of the information, she and her doctor can more easily discuss her options and share the decision.
A handful of hospitals around the country have already begun to implement shared decision making to help patients decide not just about screening tests, but also elective surgeries, like cardiac by-pass and hip replacement. At Dartmouth-Hitchcock Medical Center, in Lebanon, N.H., patients facing different health care decisions are given a chance to view a patient decision aid before discussing the options with their providers. Some patients faced with treatment choices, including surgery, decide to go ahead, while others decide to delay treatment or forego it entirely. Whatever their decision, it is well-informed.
In the case of mammography, it is entirely reasonable for women to decide to get screened beginning in their forties. It is also reasonable for them to decide against it, and neither guidelines nor their physician’s personal opinion – nor legislative mandates -- should be the deciding factor.
Shannon Brownlee is a Senior Research Fellow at the New America Foundation and author of "Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer"
E. Dale Collins is Chief of Plastic Surgery at Dartmouth-Hitchcock Medical Center and Director of the Center for Informed Choice, The Dartmouth Institute for Health Policy and Clinical Practice