We’re all tired of this topic, and unless I hear something especially goofy from the peanut gallery, this will be my last word on this subject (for the time being, anyway).
We guessed it. Both sides of the Great Political Divide went crazy and blamed either “big government rationing” or “big insurance profits” as the reason for the new paper’s recommendations. Both sides were at pains to say how much they were “for” women (I am too!). Both sides suspected a deeper conspiracy because of the timing of the paper. Nobody stopped to consider that both conspiracies can’t be true simultaneously, and that maybe—just maybe—the people who wrote the article believed what they were saying. Or, even stronger, that its findings might be correct.
Absolutely nobody I heard even made even so much as an attempt at a hint to explain “Why 40?” It’s as if beginning screening at 40 was handed down by sacred tradition, and thou shalt not question it.
Like I said, 40 might even be right for some women, but you can’t know that by any arguments you heard from the press, physicians, government bodies, and medical societies over the past three days. All we got were non sequiturs, illogical emotional probes, distractions, irrelevancies, and on and on. The closest anybody came to justifying the age was “40 saves lives,” which I hope you can agree is no sort of argument at all, merely an appeal, loosely, to authority.
We also heard, in the parade, from a handful of people who said, “The mammogram saved my life.” We did not hear from the larger group of women who never had a mammogram and never had cancer, either. Nor were there any voices from the immensely larger false positive crowd.
So I’ll tell this story again. An otherwise healthy women went for a routine screening and was told “the mammogram found something.” She went back and had another dose of radiation and still there was “something.” Days, weeks passed until the ultrasound. “Will you still love me if I have my breast cut off?” Worry, stress, tears. The ultrasound also showed something, suspiciously not in the same exact spot. Finally, a needle biopsy. Relief! It was nothing! The woman was very grateful, too. She said, “I would not have known I didn’t have cancer had I not gone through all that.” My argument that she could have saved herself all that grief had she just assumed, as was rational, that she did not have cancer; after all, she had no risk factors. She got angry with me for suggesting this. She wanted to know.
Since I have a cruel streak, I told her that she could still have cancer after all, because even biopsies are not perfect, and besides, the entire breast wasn’t sampled, just one spot. So she couldn’t actually know, she still had to rely on probability and statistics. Plus, that biopsy and all those x-rays have actually increased her risk of future cancers and other infections.
This was an email exchange and after my last comment, I never heard back from the woman.
Update Another oft-heard argument is that if we change the screening age to 50, we will miss a lot of women, from 40-50, who have cancer that could have been detected had they had a mammogram. This is true, but irrelevant; for, by the same logic, we can justify screening to start at age 15. Why? Because, of course, if we don’t start at 15, we will miss a lot of women, from 15-40, who have cancer that could have been detected had they had a mammogram.
But to say “start at 15” sounds absurd, doesn’t it? It is. And the reason it is, is the very same reason, or reasoning process, that went into the new recommendation of 50. You have to balance the costs—the actual high and very real costs—of false positives, the costs of false negatives, treatment capacities, and the important (but infrequently mentioned) base rate of the disease (per risk groups, usually; those with a family history vs. those without, etc.). This is a perfectly quantifiable calculation, and the paper’s authors came to conclusion that 50 strikes that balance. Maybe this is wrong, but they went about it the right way, and kept politics out of it.
Update I made a point to listen to Charles Krauthammer tonight. He was spot on, as his many columns usually are.