Reading about “defensive medicine and “flat of the curve medicine” remind me of an interesting topic I have discussed about from a medical anthropology class: excessive testing and its reverse effect. Excessive testing not only leads to waste of medical resources and piling medical bills, it could also result in unnecessary interventions afterwards. Because of the unique “do something” culture in U.S medical field, both the patients and physicians tend to take some sort of actions after the screening if the test appears to be anything less than perfectly negative (Black, Nease, & Tosteson, 1995). In this case, the accuracy of the test plays a critical role in the patient’s decision-making and health outcome. Performing only necessary tests and providing patients with enough information so they can make better decisions about further intervention are critical for cost-effective testing in healthcare.
Mammogram screening for breast cancer is one of the most commonly performed tests in hospitals. However, increasingly amount of evidence has raised questions regarding the effectiveness of these screenings for women who belong to the 40- 49 year-old age cohort (Humphrey, Helfand, Chan, & Woolf, 2002). Study has shown that for the 2 yearly screening policy for women aged 50-70, the cost per additional life-year gained is US $3825; for women aged 40-70, the cost per additional life-year gained is US $35000 (de Koning et al., 1991). In one mega analysis conducted by Cochrane review, 1224 women need to undergo mammogram in order to save one life (Black, Nease, & Tosteson, 1995). It is evident that drawing the line at 50 is still a somewhat arbitrary standard (Alwood JM).
However, the real cost of mammogram screening adds up when the patient decides to take further interventions either to confirm a positive test result or to treat the detected condition. According to a report by Dartmouth–Hitchcock Medical Center, 23% women had at least one false positive during 10 years of biennial screening in individual women, and for every $100 spent on screening, $33 was spent on the evaluation of false-positive result. Only 6% women were aware that mammography might detect non-progressive cancer. The aftermath only worsens in cases where invasive procedures are performed as a result of the screening. In a 1992 study of women detected with ductal carcinoma in situ (DCIS) by mammogram, 44% are treated with mastectomy, 23%-30% were treated with lumpectomy or radiation (Black, Nease, & Tosteson, 1995). One implied adverse effect is that more interventions also lead to more complications and therefore shortened life expectancy for these patients. From a mental perspective, patients also suffer from anxiety over cancer if the test result comes back positive, even though it could be false positive.
How effective mammogram is and whether further actions need to take place after a mammogram depend a great deal on how the information is delivered and interpreted by the physician. For example, early mammogram (women <50) has shown that it does decrease the mortality rate by an insignificant percentage (Andersson et al., 1988). However, if the physician uses non-specific language such as “ help reduce the risk of breast cancer” or “help extend life expectancy”, the patients are more likely to take some sort of actions depends on the test results because women tend to substantially overestimate the risk for breast cancer and the effectiveness of mammogram (Black, Nease, & Tosteson, 1995).
It is evident that sometimes the adverse effect of mammogram exceeds the preventative benefit of it. However, it does not mean that mammogram for women under 50 should be abandoned for all because different populations face different risk factors. Instead of using summary-of-evidence, generalized recommendations, healthcare providers should use more accurate language that better indicates the pros and cons of mammogram (e.g mortality reduction rate and cost per additional life-year gained) and give the patients more autonomy in making the decision about whether they want further medical intervention (Black, Nease, & Tosteson, 1995).
Mammogram is just one of the routine tests that are performed regularly in hospitals across U.S. It is not hard to imagine other tests would have the same problems. While physicians should present information to patients more accurately and cautiously, patients themselves should also take the responsibility to actively ask questions and stay informed about their conditions. Tests are certainly helpful tools if used wisely as they help physicians detect problems they would not have discovered otherwise. The important lesson here is to use tests and screening only when necessary and interpret the results rationally and objectively.
Andersson, I., Aspegren, K., Janzon, L., Landberg, T., Lindholm, K., Linell, F., … Sigfusson, B. (1988). Mammographic screening and mortality from breast cancer: the Malm? mammographic screening trial. BMJ : British Medical Journal, 297(6654), 943–948.
Black, W. C., Nease, R. F., & Tosteson, A. N. A. (1995). Perceptions of Breast Cancer Risk and Screening Effectiveness in Women Younger Than 50 Years of Age. Journal of the National Cancer Institute, 87(10), 720–731. doi:10.1093/jnci/87.10.720
De Koning, H. J., van Ineveld, B. M., van Oortmarssen, G. J., de Haes, J. C., Collette, H. J., Hendriks, J. H., & van der Maas, P. J. (1991). Breast cancer screening and cost-effectiveness; policy alternatives, quality of life considerations and the possible impact of uncertain factors. International Journal of Cancer. Journal International Du Cancer, 49(4), 531–537.
Elwood, J. M., Cox, B., & Richardson, A. K. (1993). The effectiveness of breast cancer screening by mammography in younger women. The Online Journal of Current Clinical Trials, Doc No 32, [23,227 words; 195 paragraphs].
Humphrey, L. L., Helfand, M., Chan, B. K. S., & Woolf, S. H. (2002). Breast Cancer Screening: A Summary of the Evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 137(5_Part_1), 347–360. doi:10.7326/0003-4819-137-5_Part_1-200209030-00012