Health-Care Tradeoffs

Readers, at least those in the US, have undoubtedly heard by this time that a new report by the US Preventive Services Task Force recommends that the use of routine mammograms be reduced from annual to every other year for women over 50, and be eliminated for women between 40 and 50.  I have been bemused and somewhat perturbed by some of the reaction to this recommendation (which, by the way, is just that).

Let me first say that I have not examined all of the evidence, so I am in no position to evaluate the Task Force’s recommendation.  Even if I had seen it all, I may not be qualified to fairly judge some of it.  I am not at all surprised, or bothered, that there may be some controversy or disagreement over the interpretation of some parts of the evidence.  Making a recommendation such as this one involves reviewing a mass of statistical and other evidence, and trying to make an intelligent trade-off between the advantages and disadvantages of more (or less) testing.  This inevitably involves a certain amount of professional judgment, and exactly where the trade-off should be made is a matter about which reasonable people can disagree.

That sort of disagreement does not bother me.  What does bother me is the reaction that seems to assume that no trade-off needs to be made: something along the lines of, “If even one additional cancer is detected, it is worth whatever it costs.”  The first observation that must be made is that the costs, certainly in this instance, are not just financial.  Excessive exposure to ionizing radiation (like X-rays) can cause cancer.  Follow-up biopsies have their own risks, including infections.  The Task Force’s report cited the unnecessary distress that may result from a false positive test result.  Also, of course, there are bound to be some false positive diagnoses that result in unnecessary surgery.  And the economic costs are real enough.  No one likes to think about putting a monetary value on health, but we do have to do it, all the time.

Pretending that a trade-off is not required is just a retreat to magical thinking: somehow, we can have it all if we only close our eyes and wish with all our might.  Unfortunately, when we open our eyes, we still have to grow up.

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