Map of life expectancy at birth from Global Education Project.

Monday, November 23, 2009

Grasping the Third Rail

I'm pretty sure I don't have to tell anybody how I feel about the explosion of idiocy occasioned by the new recommendations on screening mammography from the Preventive Services Task Force. Said idiocy extended across the full political spectrum and included many people -- from Dick Durbin to Debbie Wasserman Schultz -- who really, really ought to know better. Is it really smart politics to endorse Sarah Palin's depraved rantings? Because that's what they're doing.

This just proves how deeply embedded in our culture is the faith that more medical services must be better. Detecting "cancer" -- and by the way applying that label to many of the lesions found using screening mammography is debatable -- and treating it is equal to "saving lives," in the collective consciousness, so passing up a chance to do it means killing people. That someone could look at reality -- you know, the actual true world out there that we inhabit -- and do calculations, in good faith, that demonstrate that you do more harm than good by one or another form of medical test or intervention, and make a reasonable recommendation not to do so, is just inconceivable to people.

Norton Hadler's first rule of rationing is pretty simple: "If some medical or surgical act does not advantage me or my family or my patients, it shouldn't be done. I don't care how well it is done, how cheaply it is done, how efficiently it is done; if it doesn't work, don't do it." Yet we can't even accept that seemingly obvious advice. Comparative effectiveness research, which only aims to answer the question of whether an intervention does any good at all, or is better than alternatives, is equated by a large segment of the political class with Nazi eugenics, a position with which the corporate media does not, generally, take issue.

There is the occasional exception, I am happy to say. You may have seen or read about the pretty good 60 Minutes story last night on end of life care. They actually tell the tale of a dying woman who was given a pap smear. Well, it's the standard of care, right?

The basic moral proposition that death is the greatest enemy of humanity, that death can and should be conquered, and that we can and must spend unlimited resources to conquer death in the case of any given identifiable individual, no matter how desperate the straits, is the essential basis of political opposition to any form of health care reform. Even if this made sense, of course, it would not be a logically defensible reason to oppose any current legislation, but we don't even get that far with many people because their judgment is obliterated by the specter of somebody "rationing" life. How very odd that this delusional and anti-humanist position is associated most strongly with people who believe that death is an illusion and they are all going to eternal paradise.

I don't get it.

Update: Regarding the screening mammography issue, Kathy's story in the comments is actually a good illustration of an underappreciated reason for the growing caution among experts about screening. The most dangerous, aggressive cancers are unlikely to be detected early by screening because they grow too fast, in other words you're likely to have a negative mammogram and then come down with a palpable tumor a few months later. Most of the tumors detected by screening are of unclear importance: they might some day cause life threatening disease, they might just sit there and do nothing, they might in fact disappear. But when we find them we have to treat them, for better or for worse. Therefore finding more of them earlier is not necessarily a good thing. Now, the day may come when we have ways of distinguishing among lesions that will and will not become dangerous; or very quick and easy ways of eliminating early stage tumors without side effects or risks. When that day comes, early and often screening will make more sense. But that day isn't here. Medicine isn't miraculous, it's just a lot of stuff that we know and a lot more that we don't know. Sometimes, it's best to leave well enough alone.


kathy a. said...

i think that part of the problem is that breast cancer is the sexy pink cancer that everyone loves -- especially marketers with pink products in october! -- and nobody wants to sound like they are against diagnosing and treating women with cancer.

[i could do rants about pink products, AND about the cost of decor in my local breast cancer center vis a vis the great many uninisured women in that city who cannot get mammograms they need, but i probably already have.]

anyway, my sister with breast cancer sent a furious note about these new guidelines. and you know, she gets to be emotional because she has the fucking cancer. but her own rare and aggressive cancer was not detected on regular screening -- it grows fast, and is one that is frequently missed by mass screening. she falls into the underdiagnosis category; many more of us fall into the overdiagnosis/overtreatment category.

i think the new guidelines for women w/o particular risk factors are evidence-based and make sense. individual decisionmaking in light of one's personal and family history, and any symptoms, makes sense.

want to make a pitch for knowing and sharing family history. my sister's diagnosis of cancer obviously put the other sisters and me into a higher risk category. the particular and rare kind of cancer she has -- triple negative invasive ductal carcinoma -- also has health implications for the rest of us.

our aunt had a pre-cancerous condition [DCIS] which she treated with a 5 year course of tamoxifan. hormonal treatments like that do not work for my sister's cancer, and my own doctor would not prescribe hormones for my hot flashes even if i wanted that, because of my sister's kind of cancer.

irony and family dynamics alert: my sister with cancer -- the one who is angry about the new guidelines for mass screening -- did not tell me her specific diagnosis. she thinks i'm "into cancer" and [according to my fabulous aunt, who got the goods], a downer because i've known a number of people with "bad outcomes." so, whatever. i've respected her wishes not to ask about the fucking cancer, but am really glad my fabulous aunt found out, so the sisters and i can know.

kathy a. said...

oh, and my sister has done the surgery, the chemo, the radiation. her hair is back and lovely. she went on a 2 week cruise to celebrate. and she is her usual self again -- she blasted me for taking a photo of her at a family funeral that she considered unattractive. it was a great picture of her and an old family friend laughing together, but i guess all she saw was the cruise belly. sigh. family.

robin andrea said...

Reasonable, rational thinking about health care in general and cancer in particular? In our country? Surely you jest. We are well beyond the point of real discussion. Now it is all theater. And really lousy theater at that.

It's just a shame that the personal stories like kathy a's have to be lived within the backdrop and staging props of today's current madness.

kathy a. said...

thanks, robin. i don't think it's all theater, but agree there is way way too much of that.

cervantes, nice link on end of life care. i can do rants on that, too. ;)

a good part of the falling out over cancer with my sister who has it is, i support DNR's and health care directives and hospice -- when treatment isn't working, i want comfort and dignity for them. when our dad was dying of cancer, she basically wanted to sue the shit out of anyone she could find, and make him go through whatever was available. dad thought he would look like a wimp if he did not try everything, and so he died in an ICU after complications from the last chemo, instead of at home like he wanted. he did personally make the decision to remove the breathing machine, and we were there with him, so he got that much.

kathy a. said...

* by "good part," i mean "large part"

Anonymous said...

This article treats MS, multiple sclerosis, from a market perspective, that is it simply treats disease / illness as an economic opportunity.

I picked that one link but there are hundreds of articles like it out there. It is typical.

Who could possibly be keen on, or interested in, in a cure for MS unless it promised more profits?

Or heavy Gvmt. funding, then :: so sorry chaps, we spent the moolah and have nothing to show... Our research didn’t pan out...We took the cash to help you show that no cure, no new stuff, no hope, us extra.