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Striking The Balance Between Population Guidelines And Patient Primacy

Breast cancer is the second leading cause of cancer death among North American women. The American Cancer Society estimates that there will be 232,670 new cases of invasive breast cancer with 40,000 associated deaths in this year alone.

Routine screening mammography decreases the risk of death by about 15 percent; for every six women in her forties who die of breast cancer, one is saved by earlier detection with mammography. However, the research shows that 2,500 women over the course of a decade would need to be screened to prevent one cancer death. Given the low incidence of breast cancer in this cohort, the US Preventive Services Task Force (USPSTF) updated its population guidelines in 2009 to reflect findings. The new guidelines advised against routine screening mammography every one to two years in women ages 40-49. Instead, it advised screening every two years for women ages 50-74. This removed a full decade of routine screening from a woman’s calendar. To reiterate, the Task Force was not recommending against risk-based screening for someone in her forties, rather, just against routine screening.

These new guidelines were met with controversy and confusion, both from the medical community and lay public. Many women questioned the ability of “experts” to weigh potential benefits and harms of screening. Additionally, a deep mistrust intensified because the timing of these announcements coincided with news of healthcare reform, stoking potential fears that the change was a cost-savings measure.

But, here is where it is important to consider other factors in medical decision-making. The Charter for Medical Professionalism from the American Board of Internal Medicine defines three fundamental principles for physicians:

  • The primacy of the patient: the health of my patient comes first
  • Autonomy: patients have the right to make their own decisions, as long as these decisions are in keeping with ethical practice and do not lead to demands for inappropriate care
  • Social Justice/fairness: the medical profession must promote social justice in the healthcare system, including the fair distribution of healthcare resources

Physicians have a few choices when sitting with 40-50 year old patients to discuss the appropriateness of routine screening mammograms. They can:

  • Not recommend the mammogram, reviewing the evidence that routine screening is not supported for this age cohort.
  • Order the mammogram, but warn patients that it is not likely to be covered by insurance, in which case she will bear the cost.
  • Appeal the insurance company’s decision if coverage is denied. But, it should be explained to the patient that this course is not accepted if the physician would be expected to be untruthful.

Statistics show that the benefits of routine screening mammography for women under 50 do not outweigh the harms of false positives and unneeded biopsies. Some estimate that the cost of screening and the sentinel effect of false positives unnecessarily burden the healthcare system with $3.4 billion yearly. The question is: could these dollars be spent on better research and treatment that serves women of all ages? Others argue that only offering risk-based screening versus routine screening would miss many since women at high risk account for only about 10 to 25 percent of breast cancer diagnoses.

Every woman probably knows another diagnosed with breast cancer in her forties after a screening mammogram. How does a woman walk away from thinking that she may be that one in six saved by routine screening? The American Cancer Society and the USPSTF are currently re-evaluating their breast-cancer screening guidelines, particularly for women ages 40-49, since these guidelines can impact which procedures insurance companies and the state and federal healthcare exchanges will cover.

Women are not alone in facing change. Screening PSA guidelines and treatment protocols for men in their seventies have changed; MRIs were once used routinely for new low back pain screening. Routine colorectal screening is now limited to 50-75 year olds versus having no age limitation. Guidelines will continue to evolve as evidence-based screening and new technologies develop that benefit us all.

However, burgeoning healthcare demand and dwindling supply of financial and human resources are rapidly converging with those benefits. If guidelines are promulgated by respected professional organizations but not ubiquitous in execution, i.e., followed by all and for all, then how will the system provide fair equality of opportunity for all? Providing unnecessary testing, even if the cost is borne by the patient, distorts the healthcare system. Will it remain as it is today where those that have “get,” and those that don’t “get in line?”

An opinion piece in The New York Times by Drs. Pamela Hartzband and Jerome Groopman details these concepts of fairness, social justice and our responsibility for each other.

When a patient asks ‘Is this treatment right for me?’ the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment [loss of patient relationship or loss of income]? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.

This is today’s reality. We do not have limitless resources. Where does patient primacy fit with social justice and fairness? Physicians are caught in this changing landscape. Do we have a moral responsibility for each other to assure we have equal access to basic medical services? If the answer is yes, then population guidelines are the platform for change. But, change is not easy….


http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm

The Charter for Medical Professionalism from the American Board of Internal Medicine

Annals of Internal Medicine. www.annals.org November 17, 2009.

Mammograms Save Lives.Criticism of breast-cancer screenings is more about rationing than rationality DanielB.Kopans May 22, 2014

http://online.wsj.com/articles/SB10001424052702304547704579564440536353948

How Medical Care is being Corrupted: By Pamela Hartzband and Jerome Groopmannov. NYT Nov 18, 2014

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