Prevention: 1 oz.

New women's health guidelines a portent of things to come?

Date published: 11/23/2009

THE TIMING is odd, to say the least. As Democrats push hard for health care reform, opponents fire back that their proposals will inevitably mean rationing. Then new recommendations regarding less-frequent mammograms and Pap tests came out. Aha! A foreshadowing of rationed health care? Some wonder.

After all, one of the purposes of health care reform legislation is to cut costs by mandating care based on government "best practices" guidelines. But at what price?

First, mammograms: The report from the U.S. Preventive Services Task Force recommends that women delay routine breast screenings until age 50--10 years beyond the current guideline--and that these screenings be conducted every other year rather than annually. The task force found that one cancer death is prevented for every 1,904 women ages 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women ages 50 to 59. Even so, the "risks" (primarily anxiety from false positives) outweighed the benefits, the panel concluded.

But many, including the American Cancer Society, demur. Rep. Phillip Roe, R-Tenn., a retired obstetrician and gynecologist, notes: "No one ever died of extreme anxiety. People die of breast cancer."

Yes, they do: 41,000 a year. About 12 percent of American women will be diagnosed with breast cancer at some time in their lives. After a public outcry, Health and Human Services Secretary Kathleen Sebelius was quick to disavow the task force's recommendation, so official guidelines remain unchanged.

Meanwhile, the American College of Obstetricians and Gynecologists is suggesting that women wait to begin screenings for cervical cancer until age 21 (the guideline now is 18), and that they have Pap tests every two years in their 20s and every three years in their 30s instead of annually.

It's true that 70 percent of sexually active young women have human papillomavirus, but it seems their own immune systems often fight the virus off before it evolves into cancer. An abnormal Pap smear, however, generally leads to a surgical procedure to remove precancerous tissue, which in turn weakens the cervix and causes a higher incidence of preterm births. "The rest of the world is going to an every-five-or-six-year screening interval," notes Dr. Diane Harper, a specialist at the University of Missouri-Kansas City. In fact, 50 percent of cervical cancer is diagnosed in older women who have never had a Pap test.

The Pap-test recommendations are based on the "first, do no harm" medical mantra. Young women may be hurt, not helped, by overly aggressive treatment. Cutting back on mammograms, however, seems strictly pragmatic, based on a cost/benefit analysis--an "evidence-based" criterion you can expect more of if the government begins mandating health care standards.

Is it a valid standard? Maybe--if you're not the one in 1,904 women in their 40s saved from death by an "early" mammogram.

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Date published: 11/23/2009

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