Most of us know Lakoff, the UC Berkeley linguist and Professor of Cognitive Science, author of many books and several Kos diaries, the most recent being The PolicySpeak Disaster for Health Care, Lakoff's Kos diary. I waited to write about Lakoff’s inflammatory comments on mammograms and breast cancer screening, Thousands could die I wish that he had waited before launching his "thousands could die" essay- it’s too much like the politicians saying that millions may die if we don’t invade Iraq, bomb Iran, or subjugate Yemen.
You don’t start a rational conversation with "thousands could die..."
This is symptomatic of the ranting and divisiveness that passes for analysis today...
The US Preventive Services Task Force is a panel of prevention and primary care experts. They issue many recommendations about screening and primary care, ranging from abdominal aortic aneurysm screening to Vitamin Supplementation to Prevent Cancer and Coronary Heart Disease. http://www.ahrq.gov/... They issued 14 new or updated recommendations in 2009. The uproar came from Breast Cancer: Screening—Updated (2009) from their recommendation against routine mammography for women between 40 and 50 years old. They said, " The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small...This recommendation statement applies to women 40 years or older who are not at increased risk for breast cancer by virtue of a known underlying genetic mutation or a history of chest radiation. Doctor Diana Petitti, MD of the USPSTF added "So, what does this mean if you are a woman in your 40s? You should talk to your doctor and make an informed decision about whether mammography is right for you based on your family history, general health, and personal values" (November 19.2009) USPSTF recommendations breast cancer screening.
This recommendation by public health and primary care doctors was criticized by many cancer specialists and groups, such as The American Cancer Society, even though the ACS chief medical officer had admitted earlier in November that the results of breast and prostate cancer screening have been disappointing. screening disappointments
However, cancer specialists circled the wagons after hearing the USPSTF recommendations. The ACS continues to say "Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health" official ACS policy God forbid that health care dollars get away from cancer. The Air Force can’t share its budget with the Marine Corps.
An October JAMA article noted a 40 percent increase in US breast cancer diagnoses, a near doubling of early-stage breast cancers with only a 10 percent decrease in late-stage cancers that spread throughout the body. If US breast cancer screening worked in a simplistic sense, every early or indolent cancer found would be associated with a decrease in the number of aggressive cancers found- that hasn’t happened in the US (article is Esserman, et al, Rethinking screening for breast and prostate cancer, at cancer screening problems. This paper wasn’t included in the USPSTF analyses, although its conclusions are similar).
Doctor Andrew von Eschenbach repeatedly outlined a plan as head of the National Cancer Institute to end cancer death and suffering by 2015 http://www.impactlab.com/.... He strongly implied that this was possible if enough money was made available for cancer research. I never heard him ask for more money for primary care. I’m sure that his intentions, like those of Professor Lakoff, are good. I don’t have to tell you that the 2015 cancer nirvana will not happen. The NCI has a new director and a respectable web site - it says that routine mammography can reduce mortality without going into the below age 50 controversy.
American women worry about breast cancer. There were an estimated 192,000 new cases in 2009. Breast cancer is diagnosed more often in white women, who get more mammograms, but African-American women have a higher breast cancer death rate at every age and a lower survival rate than any other racial or ethnic group.
Lakoff was wrong to fulminate against the USPSTF. He worries that cost-benefit analyses may be misused, like typewriters, computers and GPS systems. He can’t defend the status quo with big differences in breast cancer death rates between rich and poor, black and white. If we’ll never have enough money for all health needs, how do we get the most bang for our buck? Do we use cost-benefit analyses, intuition or shamans?
How can we improve the health of all Americans? We can’t shovel more money into mammography. Breast cancer screening must be more available to minorities and more study of non X ray approaches is needed. If we are to screen more minorities, our screening of the affluent needs modification. Mammograms carry risk beyond discomfort and cost. They may hasten malignant change. The amount of radiation is small but if we start early and do mammograms every year, there will be some small increase in the number of women who progress to breast cancer, most evident in white women because they live the longest. We don’t know the size of this effect – tissue culture studies aren’t helpful and rodent breasts differ from human breasts. See Heyes, Mill, & Charles. Mammography-oncogenecity at low doses. J Radiol Prot. 2009; 29:A123-32. mammograms & radiation carcinogenesis
"Risk/benefit analysis, however, implies the need for caution for women screened under the age of 50, and particularly for those with a family history (and therefore a likely genetic susceptibility) of breast cancer...Whilst mammography is a low dose exposure, it is not a low dose rate examination..." This technical stuff says that multiple mammograms at an early age may accelerate carcinogenesis.
To paraphrase Brad Delong, Why oh why can’t we get better health and political advice? Americans learn very little about health in school. My generation, on the whole, is healthier than my parent’s generation, but I fear for my grandchildren’s generation. Cancer treatment is improving but there is much overtreatment in American medicine, Overtreatment book. The healthcare debates of the last three months have not sparkled. We need new voices and different approaches, combining education, social justice (Jim Wallis) and efficiency with cost-benefit analyses (Zeke Emmanuel). We must think more about health in general and not fuel turf wars between cancer, AIDS, transplants, etc.