The New Breast Cancer Guidelines: Debunking Some Myths

From the better-late-than-never department: I’ve been getting questions in real life about how I view the new mammogram guidelines, so I might as well weigh in on them here, too.

The new guidelines are only the culmination of years of research that has demolished the belief that routine mammograms for women in their forties will save lives. I’ve been following the medical debates on early detection of breast cancer ever since a Danish metastudy challenged the efficacy of routine screening mammography back in 2001; Gina Kolata reported on this study for the New York Times, and she’s done a fabulous job of following the controversy ever since. Feminist advocacy groups, such as the National Breast Cancer Coalition, have long questioned the advisability of regular mammograms for women under 50. Basically, mammograms pick up a lot of false positives and miss a lot of actual tumors. They also result in treatment of cancers that may never become dangerous. For breast cancer (unlike, say, colon cancer), early detection is no panacea because cancer cells often metastasize very early on. The scientific evidence really is pretty compelling. I’m not going to dissect it here, but see Our Bodies, Our Blogs and Echidne as well as the excellent and very thorough analysis by the NBCC.)

Instead, I’m going to tease apart some myths and misconceptions that have muddied the debate. Most are coming from those who’ve criticized the new guidelines. (And no, I’m not even going to bother with Rushbo’s revival of the death panel canard; Echidne snarked it into oblivion already.)

First, the new guidelines have been accused of being racist, as in this post at Feministing. Note, though, that the guidelines in no way discourage routine screening of women who are at higher than average risk; instead, they propose evaluating each woman’s particular risk. Compared to other ethnic groups, black women are indeed at higher risk of developing breast cancer in their forties. The new guidelines are thus simply inapplicable to black women, since they only address women who are at low risk. Black women should definitely get routine screening earlier than white women. By now physicians should be aware that breast cancer discriminates by race; to the extent that they’re still clueless, what’s needed is better awareness through continuing medical education. The new guidelines call for individualized risk assessment, not cookie-cutter methods. If this doesn’t work for women of color – and I agree there’s a chance that it won’t – then the problem isn’t the new guidelines, it’s that racism, ignorance, and profit-based medicine are interfering with individualized care.

Second, the media is teeming with heart-rending stories about women who find a lump and who wouldn’t have gotten diagnosed under the new guidelines. While stories about the human costs of cancer are really important, these stories are completely irrelevant to the debate. If you find a lump, your doctor will send you for a diagnostic mammogram. The new guidelines only address screening mammograms, which are done at regular intervals without any reason to suspect cancer. The new guidelines say nothing about diagnostic mammograms, which have never been controversial.

Third, the new guidelines don’t have any binding power. I do think it’s reasonable to worry that insurers will refuse to cover mammograms for women under 50, just because insurers are always looking for ways to cut costs. That would be a gross misapplication of the guidelines, which call for women and their doctors to decide whether screening mammograms are right for them. I’m fairly sanguine about this, though, because the breast cancer lobby is strong enough – and the public outcry loud enough – that insurers are far more likely to cut corners elsewhere.

Fourth, there’s no evidence that the revised guidelines are motivated by sexism. Routine PSA screening for men has recently been challenged on very similar grounds. While prostate cancer survivors have been just as skeptical as breast cancer survivors when it comes to decreasing early detection efforts, they haven’t enjoyed a similar bully pulpit. Nor have men in general risen up in protest. Perhaps Sir Charles of Cogitamus is right in linking this apparent apathy to more basic tenets of masculinity:

Not to engage in gender essentialism, but I think this may have to do with the fact that men are always comfortable with a recommendation that reinforces our tendency toward denial in these kinds of matters — oh the test is no good — great, I’ll skip it. (Or maybe I’m just projecting.)

At any rate, men and women face similar issues here, not fundamentally different ones. The conversation about what we gain and lose through massive screening campaigns is one that both men and women ought to be having.

Proponents of the new guidelines (including Echidne, whom I otherwise agree with) are also making one wobbly assumption: that funds not spent on screening mammograms will be redirected to areas where we’ll get more health for the buck. I’m skeptical. Insurance coverage of mammograms has been mandated by law. If those laws should change (and I’d be surprised if they did), insurance companies would more likely divert the funding for mammograms straight to their bottom line (see point three above). They’re looking to cut corners wherever they can. Sober policy analysis of costs and benefits needs to take good old fashioned greed into account, too.

So by all means, let’s have a debate about the limits and possibilities of early detection and huge screening campaigns. But let’s have it on the basis of facts, rather than using the new guidelines as a Rorschach blot for our hopes and fears. (I have more to say about those fears, but that’ll have to wait for another day.)