The news stories this past weekend about the new guidelines for breast cancer screening in Canada were a déjà vu for me. It took me back some fifteen years when in addition to bringing perfectly foamed cappuccinos to the politician chair I took part in contributing to the gathering and analysis of the research as well as guiding and recording the discussion in Alberta’s examination of the breast cancer screening program.
Today’s news brought me back to the exact same controversy. Should women between the ages of 40 and 49 be included in breast cancer screening programs or should the focus of population wide screening programs be on women over 50 years of age and those under 50 who are at high risk for breast cancer? Should the focus be on the group for whom the benefits of screening are achieved?
Apparently the same issues are still being bandied about. What is important to know is that the issues have nothing to do with what makes sense for the health of women in general. The same arguments are being made. The group that has examined the issue of breast cancer screening from the benefit for women perspective presents their guidelines and the people who make mammography their business do not like the guidelines that essentially reduce their business.
Let me set the context:
The new guidelines for breast cancer screening prepared by a Federal Task Group and published in the Canadian Medical Association Journal just last week set the standard for the country. If the guidelines are to be followed several provinces, Alberta and British Columbia included, will no longer be screening women between the ages of 40 to 49 years of age as routine within their breast cancer screening programs. This is already the practice in Ontario, so the guidelines do not impact women in that province.
The Canadian Task Force on Preventive Health Care examined the research evidence and determined that “women who have routine mammograms face the risk of false positives, which set off a string of unnecessary tests and treatments and cause needless anxiety. The researchers also say screening can find cancers that grow so slowly they would never affect a woman in her lifetime. The task force found the harms of over-diagnosis were greater for women between the ages of 40 and 49.”
Therefore they note that the focus of population based screening programs should be on women ages 50 – 69 with a recommended breast x-ray every two to three years instead of every year or two. Of course they also note that women who are at high risk would continue to access mammography as required.
Now there are always the few and far between cases of individuals who have benefited from early mammography and the guidelines in no way restrict mammography for women of any age. Instead they recommend moving away from conducting mammograms on all women within the 40-49 age cohort group because of the potential harms as outlined above. Harms that affect more individuals than individuals who benefit from early diagnosis.
Now this is where the controversy comes in. The Canadian Association of Radiologists declare that women will die and through the cooperation of the media have presented stories of women in their 40’s who have been diagnosed with breast cancer thus implying that these guidelines will have put these women at risk of dying from the disease. This adds confusion to the mix and leaves Canadian women puzzled and anxious about what is the right thing for them to do.
Sounds just like the same arguments that the Alberta based radiologists made when Alberta was reviewing and structuring their breast cancer screening program some fifteen years ago. This was an argument that the government fell for instead of going with the research (not much different than that which has just been presented this last week).
There have been hints in the media that perhaps the radiologist are in a conflict of interest position given that they work on a fee-for-service basis which is just a sophisticated form of “piece-work”. They deny that this has anything to do with their disagreement with the guidelines. But I wonder, let’s see what this might mean. I’ll pretend I am a radiologist:
“If I get paid for every mammogram I do and if the guidelines are applied I will no longer be doing regular mammograms for all women ages 40 -49, doesn’t that mean I will be doing a lot fewer mammograms and therefore I will make less money?”
I have heard the radiologist’s retort to this simplistic thinking: that they only care about women, their health and preventing the unnecessary deaths of women. But frankly I just do not buy it. It is crystal clear that this is a case where the business/economic model which has been inappropriately applied to our “health care” system, and which has made it into an illness industry, clouds our thinking and ability to make decisions about what makes sense for people and their real health. To believe that the radiologists are not just using an economic lens to view and comment on this issue and that they are truly only interested in the health of women is a long a shot at best. If there is case to be made that has not been considered by the Task Force, let’s hear it. More importantly let’s give the women of Canada the straight goods and stop confusing them and adding to their anxiety and fear.
Here are a few links (a few days old)to some new stories about this issue:
Read the guidelines, think and make a choice about your need for mammography that makes sense for you.
Irene McDermott © 2011