Following where scientific evidence leads in deciding medical care isn’t ‘rationing’

EDITOR:

The current dustup about mammography, a widely used and valuable X-ray procedure for early detection of breast cancer, cries out for less hysteria and more respect for plain truth. Let’s try to separate the facts from conjecture, starting with a bit of history.

When mammography first achieved wide acceptance in the 1970s, it was recognized that the procedure had little value for women in their 20s and 30s because few of them had detectable evidence of malignancy and many would show shadows on their X-rays that were benign but looked like possible cancers, and therefore had to be removed surgically (biopsied) to be certain. After age 50 the procedure had unquestioned value, and doing it annually seemed like a good idea. It was recommended not to do the test in the years between 40 and 49 because the risks seemed to outweigh the benefits. However, testing during that decade has become common for a mixture of reasons. One of these is meeting the needs of women who have inherited a high risk for breast cancer. Others include anxiety, activism and commercial considerations.

Now comes a new report from the United States Preventive Services Task Force, an authoritative source of analysis of the best scientific information on preventing disease, disability and early death. Basically, they have used accumulated high-quality research results to refine and confirm the recommendations made in the 1970s: begin doing routine mammography at age 50, although it can safely be scheduled less often than yearly. Women with family medical histories that suggest that they may be at increased risk for the disease should start earlier.

In the real world of health care, physicians and patients should have “wiggle room” to modify these standards somewhat, not because variations will cause better outcomes but because normal human emotions sometimes need to be accommodated. This matter is addressed insightfully in a Nov. 23 Vindicator editorial.

A pair of essays on The Vindicator’s Nov. 25 oped page illustrate very well the two sides of this issue. In one, a Seattle newspaper columnist expresses some opinions that can lead to fixation on cancer risks and exaggeration of what scientific reports actually say, while clinging to practices that, for limited populations only, favor early detection of life-threatening disease. In the other, a physician with intense interest in battling breast cancer offers an excellent overview of the facts needed to respond wisely to the excesses of the present controversy.

The push to use mammography only when it can be beneficial has been called “rationing,” but that’s pure falsehood. Rationing has been used as a bogeyman by those trying to scuttle the current drive in the U. S. Congress for much-needed health-care reform legislation. My childhood memory during World War II has a very different flavor: rationing of gasoline, sugar and even shoes was inconvenient, but we accepted it as a fair and necessary part of the war effort.

The needs of the American people for health care today cannot be met without bankrupting the country unless we as a nation realize that we can afford all of the medical services that we need, but not all that we want. We must accept some form of limits on fruitless or potentially damaging treatment (call it rationing if you must), or the cost of medical services will cut increasingly into our ability to do other important things like education, national defense, care of the elderly and investing in the nation’s future. Already, one dollar of every six spent in our country goes for medical expenses, and the proportion gets worse every year.

ROBERT D. GILLETTE M.D.

Poland