Slate writers and editors debate the ramifications of new cancer-screening guidelines.

Conversations in real time.
Nov. 20 2009 3:51 PM

Opening the Screening Door

Slatewriters and editors discuss whether new cancer-screening guidelines should be considered a harbinger of health care rationing.

(Continued from Page 1)

Saletan: I don't think screening is what the cost-containment advocates are talking about when they talk about preventive care. But to the extent they do (presumably to exploit women and families with cancer), this is a good opportunity to kick them in the ass.

Larimore: I think it's fascinating that we're figuring out that there are cancers that won't progress, and I liked the "XX Factor" post saying we need a Pap-like test for breast cancer. (At least until they start rationing those! Kidding.) But until we know more and until there are better tests, it feels like we're reducing our best methods for preventative care without anything to replace them.

Emily Bazelon: But the thing is, these aren't our best methods. That's what the evidence-based findings show. They're just the methods we're used to. And the reason the federal task force was taken by surprise is that politics isn't what it was designed for when it was set up back in 1984.

Hanna Rosin: If you were going just by the science, you would do a lot less screening. Mammograms are a perfect example. The mammogram's utility should be judged by how well it prevents deaths in a large population. Instead, we judge it by how accurately it picks up cancer in one individual. The former would, in fact, be an argument for rationing. The latter leads everyone to want a mammogram, though it is irrational and unhelpful. Ditto for prostate screenings.

Bosch: The problem is bridging the divide between the push for science-based medicine and the way patients are encouraged to be their own advocates—from marking your thigh with a Sharpie before surgery to ensure the surgeon amputates the correct leg to questioning the medication dosages your doctor prescribes. We've backed away from the idea that every doctor is omniscient, but we seem to have gone too far in the other direction. The patient-as-advocate model is also what's partially responsible for "adjusted" vaccination schedules, overprescribing antibiotics, etc. The shift in power has thrown things off-kilter.

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Bazelon: 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? These 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.

Saletan: Well said. Cost control means some people will die, and medicine without cost control is financially unsustainable. Palin is just playing to Americans' age-old denial of this reality.

Dickerson: There's not a lot of cost containment that comes from preventative care in the bills we're talking about. The Congressional Budget Office scores preventative measures as costing money, I believe. So there aren't claims being made about the power of preventive care to save big money. When Obama talks about preventive care, he's talking about how it's better to have an annual checkup to find out that you have diabetes than waiting until you're so sick you have to go to the emergency room.

In terms of prevention, he also lists mammogram screening—not because he's got a particular jones about the science but because his plan tries to give people access to whatever the basic set of preventive measures are as an act of fairness. If those measures change over time, fine. That's the whole point of comparative effectiveness, the other thing that the president talks about and that critics immediately claim is rationing. Presumably, if doctors decided that what was once considered preventive is now expensive and full of false positives and bad health outcomes, a well-functioning comparative-effectiveness system would spread the word so that doctors could make intelligent decisions with their patients based on the latest research. This comparative-effectiveness scheme would guard against a mindless mantra in favor of or against preventive measures and base decisions on actual studies, ultimately leaving the decision to the doctor and patient. Critics, of course, claim that spreading information about studies immediately equals rationing.

And here comes the White House on this topic.

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