Screening for Breast Cancer: Do I do it or not?

A blog post by Lauren Citron, Jenni Jung, Shilpa Narayan, and Yena Son

If you are young and healthy, you should probably hold off on breast cancer screenings. Yes, we know the technology is available. We also know that a mammogram screening to detect breast cancer is an important preventative measure.

However, overdiagnosis and treatment has led to out-of-control spending within our healthcare system. This is why in 2009, the United States Preventative Services Task Force, an independent panel of experts in the federal department of Health and Human Services (HHS), recommended starting regular breast cancer screenings at age 50, not age 40, and to reduce preventative screenings from annually to biennially. Their guidelines even recommended that doctors stop telling women to examine their breasts for lumps regularly.

Not necessarily “better safe than sorry”

Breast cancer screenings are not necessarily helping patients. On average, they may be harming them instead...

Studies show the following:

• As many as a third of breast cancer patients do not require treatment.
• Among women who did and did not receive mammograms, mortality was the same, despite higher diagnosis and treatment among women who found tumors through mammograms.
• 20 percent of treated tumors are not fatal and do not require intensive interventions such as chemotherapy and surgery.

This is because our technology is currently so advanced that we can even detect tumors that are growing so slowly that it will never become a risk to the patient during her natural life.

Yet, patients mistakenly assume that undergoing more tests and treatments is the same as receiving better care. Excessive screenings and unnecessary treatments must stop.

Reduce Unnecessary Screening and Treatment

We need representatives from Congress, members from HHS and the U.S. Preventive Services Task Force, insurance providers, the American Medical Association (AMA) and patient advocacy groups such as the American Cancer Society to get together. This working group should create standardized definitions, begin collecting data and measurements, and analyze current research, and ultimately form new recommendations on preventive screenings.

The U.S. Preventive Health Task Force should hold a leadership role in forming the group. In fact, we suggest they create a time limit to encourage parties to be willing to compromise on who receives a seat at the table, how often and how big a say in recommendations each stakeholder receives.

In the meantime, working groups to develop metrics and standards may be more feasible at the state level. For example, Washington and Oregon are taking actions to reduce health spending due to overtreatment.

After developing the appropriate level of preventive screenings for breast cancer and other diseases, this group should ask the government to publicly endorse this recommendation. Insurance companies and doctors should then be encouraged to take these standards into account when making recommendations to individual patients on coverage and treatment.

That’s a big group. Can we get buy-in?

We thought you might ask that. Here’s our take on how the most important stakeholders would respond:

Insurance Companies

It is probable that insurance companies will change coverage according to the new recommendations, especially when the recommendations involve raising the age or reducing the number of screenings. That is because according to the Affordable Care Act (ACA), insurance companies are responsible for covering the recommended preventive medical screenings. It is likely the age will be increased to reduce overdiagnosis and over-treatment in the near future but as research is conducted, the number of recommended screenings may once again be increased. Since it is easier to convince groups to be on board when the benefits are tangible now and future cost increases are less certain, insurance companies will likely support the present plan, creating a precedent for insurance companies to follow the working group’s guidelines.

Doctors

Doctors may disagree with the guidelines either because they believe these guidelines will hurt the patient or will hurt themselves financial due to the fee-of-service system (though the ACA is beginning to change this practice through pay for quality). They are then constrained by what is covered by insurance, which will likely reflect the government’s recommendations. Physicians should still be given the discretion to run the tests and screenings if they believe it is in the best interest of the individual patient. Providing doctor autonomy to act on the individual level and placing physician groups, such as executives from the AMA, on the working group may mitigate this concern and build trust.

What About the Patients?

Ultimately, a reformed screening standard will help patients on average. They are also anticipated to be the most resistant to our recommendation, since the overall benefits will come at the expense of some individuals. While some tumors are benign and patients will benefit from lack of treatment, there are other individuals whose condition could have been successfully treated had it been caught in early stages with earlier screenings.

Don’t Go, Status Quo!

Although most patients may be better off in the future without undergoing preventive screening and invasive treatments, patients are reluctant to reduce current screening practices because they see this as a departure from current practices. We are more reactive to potential losses, and often fail to consider the costs of action on our physical and emotional well-being. Current policies and practice reflect this aversion to loss.

If You Found It, Shouldn’t You Fix It?

We also take more stock in harms induced by action than in harms arising from inaction. Patients also tend to underestimate the possibility that their tumor will be benign. Because a course of action is readily available and easily identifiable (through pre-screening technology finding even the smallest tumors), patients are biased toward taking action to prevent potential harms. This is the case even though inaction may be a more rational choice, saving the patient physical and emotional stress as well as high financial costs for low expected gains.

Patients need clear, explicit data on the potential gains for not doing screenings or invasive treatments. This is especially true for certain subpopulations who tend to face lower risks on average for the diseases in question. Patients - along with their physicians - need more information and appropriate guidelines so they can fully weigh the losses from invasive surgery against the potential benefits. This information can be collected and made publicly available by the working group.

I Still Want The Screening!

Okay. Sure. After weighing their choices, patients should still be allowed to ask for additional screenings. But there’s another built-in motivation to not get unnecessary screenings: you’ll probably have to pay more! It is likely that if screenings are conducted outside of the recommended time period, they will not be fully covered by insurance. A copay limit - such as $50 per mammogram under the age of 50 or more frequently than every other year - could be put in place for middle and high income patients. Low income patients could be fully subsidized to avoid disproportionately affecting those who cannot afford to pay. This recommendation shares the cost, leaving options on the table to protect individual choice while reducing the overscreening that currently occurs in the United States medical field.