The Wall Street Journal
NOVEMBER 19, 2009
A Breast Cancer Preview
The mammogram decision is a sign of cost control to come.
A government panel's decision to toss out long-time guidelines for breast cancer screening is causing an uproar, and well it should. This episode is an all-too-instructive preview of the coming political decisions about cost-control and medical treatment that are at the heart of ObamaCare.
As recently as 2002, the U.S. Preventative Services Task Force affirmed its recommendation that women 40 and older undergo annual mammograms to check for breast cancer. Since regular mammography became standard practice in the early 1990s, mortality from breast cancer—the second leading cause of cancer death among American women—has dropped by about 30%, after remaining constant for the prior half-century. But this week the 16-member task force ruled that patients under 50 or over 75 without special risk factors no longer need screening. [As a matter of fact, it was only 6 MONTHS AGO -- before health care legislation had moved to the front burner -- that this panel re-issued its own WARNING about the importance of early breast cancer detection, annual mammograms after age 40, and self-examinations. Now we have their VERY ABRUPT reversal of a VERY longstanding opinion, which for many years had concurred with the American Cancer Society's recommendations. The government panel has suddenly decided to oppose the ACS's recommendations -- on the basis of absolutely no new medical evidence.
So what changed? Nothing substantial in the clinical evidence. But the panel—which includes no oncologists or radiologists, who best know the medical literature—did decide to re-analyze the data with health-care spending as a core concern.
The task force concedes that the benefits of early detection are the same for all women. But according to its review, because there are fewer cases of breast cancer in younger women, it takes 1,904 screenings of women in their 40s to save one life and only 1,339 screenings to do the same among women in their 50s. It therefore concludes that the tests for the first group aren't valuable, while also noting that screening younger women results in more false positives that lead to unnecessary (but only in retrospect) follow-up tests or biopsies.
Of course, this calculation doesn't consider that at least 40% of the patient years of life saved by screening are among women under 50. That's a lot of women, even by the terms of the panel's own statistical abstractions. To put it another way, 665 additional mammograms are more expensive in the aggregate. But at the individual level they are immeasurably valuable, especially if you happen to be the woman whose life is saved.
The recommendation to cut off all screening in women over 75 is equally as myopic. The committee notes that the benefits of screening "occur only several years after the actual screening test, whereas the percentage of women who survive long enough to benefit decreases with age." It adds that "women of this age are at much greater risk for dying of other conditions that would not be affected by breast cancer screening." In other words, grandma is probably going to die anyway, so why waste the money to reduce the chances that she dies of a leading cause of death among elderly women?
The effects of this new breast cancer cost-consciousness are likely to be large. Medicare generally adopts the panel's recommendations when it makes coverage decisions for seniors, and its judgments also play a large role in the private insurance markets. Yes, people could pay for mammography out of pocket. This is fine with us, but it is also emphatically not the world of first-dollar insurance coverage we live in, in which reimbursement decisions deeply influence the practice of medicine.
More important for the future, every Democratic version of ObamaCare makes this task force an arbiter of the benefits that private insurers will be required to cover as they are converted into government contractors. What are now merely recommendations will become de facto rules, and under national health care these kinds of cost analyses will inevitably become more common as government decides where finite tax dollars are allowed to go. [IE, it is THIS PANEL which will be tasked with / authorized to determine what procedures will or won't be allowed for whom, under every single version of Health Reform Legislation sponsored by the Democrats. With the passage of any of these bills, this panel's recommendations will become the rules under which medical care is provided, BY LAW. Reminder: there are NO oncologists and NO radiologists on the panel. -- Morry]
In a rational system, the responsibility for health care ought to reside with patients and their doctors. James Thrall, a Harvard medical professor and chairman of the American College of Radiology, tells us that the breast cancer decision shows the dangers of medicine being reduced to "accounting exercises subject to interpretations and underlying assumptions," and based on costs and large group averages, not individuals.
"I fear that we are entering an era of deliberate decisions where we choose to trade people's lives for money," Dr. Thrall continued. He's not overstating the case, as the 12% of women who will develop breast cancer during their lifetimes may now better appreciate.
More spending on "prevention" has long been the cry of health reformers, and President Obama has been especially forceful. In his health speech to Congress in September, the President made a point of emphasizing "routine checkups and preventative care, like mammograms and colonoscopies—because there's no reason we shouldn't be catching diseases like breast cancer and colon cancer before they get worse."
It turns out that there is, in fact, a reason: Screening for breast cancer will cost the government too much money, even if it saves lives.
[And that money is needed for bailouts -- ie corporate welfare to the top 1% of the nation's business firms -- as well as for stimulus packages and all the pork and earmarks so crucial to keeping our essential political elite comfy in the style they've become accustomed to. -- Morry]
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THE RELEVANT FACTS:
In England today, the success rate for curing breast cancer is 2 out of 4 cases. (Many cases become terminal while the woman is waiting for surgery.) In the US it is 3 out of 4. Breast cancer strikes roughly 12 % of women. This means that breast cancer will strike roughly 18 million women who are alive today in the US. Of those our present system, if it survives, will cure 13.5 million; the British system would cure 9 million. There is no reason to believe government run medical care in the US will be any more successful than it is in Britain. Indeed, Hillary Clinton and others have praised the British system and stated that we should do more or less the same thing in the US. This means that of the 18 million victims of breast cancer, 4.5 million will die unnecessarily. It is not unreasonable to expect that 4.5 million women, alive and healthy today in the US, will be killed by ObamaCare.
And that is just breast cancer. Consider colon cancer, prostate cancer, heart disease, . . . .etc.
THERE IT IS, FOLKS, THE 1st step to be taken by ObamaCare to fulfill its promise of making healrh care affordable. It's so simple, it's amazing no one thought of it before!! We inaugurate the plan with the beautiful-in-its-simplicity step of killing 4.5 million American women. True, this will only cut medical costs by 1 or 2% overall, but don't lose heart!! Remember, there's still colon cancer, lung cancer, prostate cancer, bladder cancer, stomach cancer, heart disease, lung diseases, etc, etc,etc, each one a very promising area for effecting further cuts. We will probably be able to cut costs by up to 20% or more simply by arranging for the premature deaths of another 40-60 million Americans. True, simple tort reform has cut costs by an average of 30% in the few states which have enacted it, but this would be unfair to lawyers, as the currently considered Senate bill wisely recognizes. Lawyers are necessary because they are huge contributors to the Democrats' campaign chests, and the nation needs all the concerned, big-hearted Democrat accessories to murder it can get. (The bill currently under consideration in the Senate explicitly provides for substantial cuts in Federal funding to any state which places any restrictions or limits on awards in medical cases.) So . . . KUDOS FOR OBAMACARE. It's the smart way to go, and even if it is grossly dishonest and literally murderous, this is just part of the nature of many politicians, and in a nation of diversity, we must accomodate their viewpoint. So let's patch up our differences and all join together with the nation's medical malpractice attorneys and with our hard-working morticians in praising the virtues of ObamaCare!! -- Morry