The Doctor Is In: Where new screening guidelines for women go wrong

I've been inundated by questions from patients and friends over the past few weeks regarding two recent recommendations concerning cancer screenings for women. The big worry that keeps coming up is "are we rationing women's health care?" That's because first, the U.S. Preventive Task Force on Nov. 16 recommended against routine mammography for women under 50 and called for regular screenings every other year instead of annually thereafter. The group also downplayed the usefulness of conducting regular breast self-exams.

A few days later, the American College of Obstetricians and Gynecologists (ACOG) released new cervical cancer screening guidelines stating that women should begin having Pap tests at age 21, then every other year between 21 and 29. The previous recommendation had called for women to begin annual Pap tests a few years after their first sexual activity, or by 21, whichever comes first.
These controversial recommendations have touched off a heated debate over whether mammograms in your 40s and Pap tests for teenagers save lives or merely create added cost and anxiety because they result in so many extra tests and procedures. In addition, critics of the proposals view them as health care rationing and warn that they're a sign of things to come if "Obamacare" is enacted.

Pap Tests Led to a 70% Drop in Cervical Cancer

It seems everyone -- women's health advocates, breast cancer survivors, Republican and Democratic lawmakers -- has an opinion on this topic. And they are all vying for airtime on cable TV. Occasionally, a scientist or doctor gets to add a medical opinion to the mix.

Here's mine: Like most physicians, I am generally accepting of evidence-based medicine and embrace the concept of cost effective care. But I'm also cautious about scaling back cancer screenings. Every OB/GYN physician I know has had patients who have had early breast cancer diagnosed by mammography in their 40s and has seen how early intervention can save lives.

Nowhere is this more clear than in cervical cancer screening. The Pap test has led to a 70% decline in rates of cervical cancer in the U.S. since the test was introduced more than 50 years ago (that's not true of all cancer screening tests). So not only is the test saving lives, but it's saving young women's lives.

While abnormal Pap test results are extremely common, precancerous cells known as dysplasia often disappear without any treatment in younger women and can be followed carefully without aggressive treatment. However, I have also seen more serious high-grade lesions with potential for cancer in this group. Sadly, most of us have also witnessed at least one case of cervical cancer in this population. As you might imagine, these are the cases and faces that keep me awake at night.

The American College of Obstetricians and Gynecologists team reasoned that "screening before age 21 should be avoided because women less than 21 years old are at very low risk of cancer. Screening these women may lead to unnecessary and harmful evaluation and treatment. Evidence shows that screening women over 21 every year has little benefit over screening every other year."

Fewer Unneeded Tests and Procedures Is a Worthy Goal

There is valid concern about the extra procedures on young women and how they might affect fertility, for example. However, doctors can now manage abnormalities less aggressively and less invasively most of the time.

In terms of mammography screenings, the task force acknowledges that for every 1,900 mammograms performed on women in their 40s, one life is saved. They question whether this is cost-effective. I am sure that the one in 1,900 woman who survives because of the current guidelines would argue that it is. Assuming there's a limited number of health care dollars we can spend -- and that we have to set priorities for how we spend -- is this really where we want to make major changes?

The money saved from both of these recommendations is a pittance compared to what we could save elsewhere by cutting unnecessary tests and procedures, and other waste in the system. There are so many unnecessary tests and procedures done it's almost criminal -- and doctors are complicit because they do it to prevent lawsuits and make extra money.

A good place to start is taking a hard look at costs associated with caring for patients at the end of life -- without the political hogwash of the so-called death panels -- and exploring how to curtail costs without sacrificing patient care.

What's the alternative? As I said in one of my first DailyFinance columns last spring, I support what's known as comparative effectiveness, the idea that enlisting a team of experts to study cost-effectiveness can reduce unnecessary medical care and spending. This type of research is sorely needed to provide physicians with better information so they'll have a clearer idea if a more costly treatment is actually more effective than cheaper alternatives.

Comparative Effectiveness Isn't Rationing


It will also help control spiraling health care costs by preventing the health care system and patients from spending money on unproven technology and drugs. But it doesn't have to be at the expense of people's lives.

This is not rationing; it's providing good medical care. Both versions of the health care reform bill include increased funding for comparative effectiveness research. However, if you're going to do this, it better be done right. And by the looks of it, the U.S. Task Force may have missed the mark this time.

What's disturbing is that the expertise and credibility of the mammogram task force members has come under scrutiny. I haven't seen a single prominent scientist applaud the results of this recommendation, whereas the American Cancer Society, the American Society of Breast Surgeons, the American College of Obstetricians and Gynecologists and untold number of breast cancer survivors and advocates have denounced the recommendations.

Cost-effective health care policy as envisioned by the Obama administration must clearly walk a tightrope between denying coverage for wasteful care and allowing physicians the leeway to individualize care on a case-by-case basis. When a young woman should begin Pap test screening is just such an example.

For most women, a Pap may be delayed until age 21. For others, specifically, those who become active at age 12, 13 or 14, they shouldn't wait until they're 21. Most of these young women who contract the HPV virus (a common infection spread through sexual contact and causes most abnormal Pap tests results) will clear the common low-grade precancerous lesions they develop. But not all of them will.

Insurance Denials Are a Valid Concern


I plan to continue to individualize my recommendations for Pap smears as well as mammography, just as the Task Force and the American College of Obstetricians and Gynecologists recommend. The question is: Will my decision be honored in terms of having these procedures covered by insurance carriers?

Given the profit-driven ways of the insurance industry, they will use these new recommendations to deny even more medical care, hence the outcries over rationing. This is a valid concern. Though there would undoubtedly be a backlash from women's groups as well as physicians if this occurs, insurance companies have a well-established track record of making unpopular, arbitrary decisions and policies.

After the White House initially backed away from the mammography recommendations, I was fairly confident health insurance companies wouldn't use the task force's advice to determine what's covered or not. However, not long after the new guidelines were released, CNN exposed language in some of the health care reform legislation mandating that coverage of certain medical care follow the task force's recommendations. Given that the language in the bills is in constant flux, it's unclear if this will remain in the final bill.

Last but not least, another problem is that both of these recommendations send the wrong message to women: Doctors have been trying to convince women to undergo cancer screenings for years. Now some women may think, "Hey, maybe we don't really need it." Those who skim the headlines may believe they no longer need to be seen for an annual gynecological exam where other abnormalities besides cervical cancer are assessed, or they may think they can skip medical screenings altogether, especially if they are not covered by health insurance.

Russell Turk, M.D. is an obstetrician and gynecologist in Fairfield County, Conn.

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