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UC Denver Voices

Too much health care vs. too little


Colorado citizens may wonder about new cancer prevention guidelines mixed in with efforts by Congress to reform American health care. After all, it's quite natural to link recommendations for fewer mammograms with reforms designed to overhaul the world's most expensive health care system.

Yet, these two bits of health news are unrelated. For at least twenty years, medical experts have questioned whether a mammogram is an appropriate test for all women in their forties. It turns out that during the ten years between ages 40 and 50, for every woman whose life is saved by a mammogram, over 1,200 women undergo yearly mammograms with potential downsides of pain, anxiety, negative biopsies, radiation exposure, and overdiagnosis.

So, for standard risk women in their 40's, routine mammography may simply cause more harm than good. In situations like this, doctors and patients alike must look to experts who consider the risks and costs to a society of a particular disease prevention strategy.

We heard from these experts last month, and unfortunately, the timing of their announcement allowed critics to say that updates about cancer screening were part of a governmental plan to ration care. Simply untrue.

Yes, at this particular time, the release of controversial mammography guidelines seems politically naïve, but that helps to confirm that the United States Preventive Services Task Force is a totally independent group, totally focused on scientific evidence and public health. Likewise, the concept of Pap smears for many women on an every three year vs. yearly basis may be unfamiliar and may seem like an overly cost-conscious approach, but this guideline about followup Pap smears first reached the practicing physician in 1987.

And for those who see gender bias in the recent guidelines or still cannot let go of the "more tests are better" concept, please know that support for routine PSA testing for prostate cancer detection will soon be at an all-time low, as American physicians respond to major study results that suggest that routine PSA testing also causes more harm than good.

So more care is not necessarily better care. Yet, no care for millions of Americans is the worst arrangement of all, a shameful state of affairs that could end if Congress enacts legislation to expand Medicaid and provide affordable insurance coverage.

In this manner, we may alter the grim fact that lack of access to medical care results in thousands of preventable deaths and billions of wasted dollars devoted to the treatment of preventable disease. As things stand, the trend of accelerating health expenses threatens to consume 40 percent of a middle class family's income by 2020. Expenses like that a decade from now would signify a society in poor health.

So, too much testing may be harmful and is certainly costly. No care at all is more hazardous and costs even more. Health practices like mammography, driven by science and reason, are good for people. Health care reform would be even better. In fact, there actually is a link between recent health reform efforts and recent guidelines about cancer prevention - both are in the public's best interest.

Lawrence E. Feinberg, MD, is a general internist, Professor of Medicine at the University of Colorado School of Medicine and President of the Colorado chapter of the American College of Physicians.