Respectful Insolence

I knew when I first heard about them that the new United States Preventative Services Task Force (USPSTF) recommendations on breast cancer screening would be controversial. I tried to discuss these guidelines and the issues involved in a calm and rational way, relatively devoid of Insolence, Respectful or not-so-Respectful, yesterday, pointing out that screening guidelines were clearly due for revision but also recognizing the problems with the USPSTF recommendations and valid criticisms of them. In the end, I concluded that, among the critics, the ASCO discussion of the proposed guidelines was the most reasonable At the same time, this being Orac and all, I couldn’t resist snarkily dissing at least one overblown and unjustified criticism of the guidelines, coming from, embarrassingly, a professional organization to which I belong.

One day later, I realize that the example of a brain dead and hyperbolic attack of the new guidelines was nothing compared with what was to come and, I suspect, still is to come. Although some attacks are just misguided and based on erroneous information, a lot of them are truly nothing more than appeals to emotion and logical fallacies. Indeed, the stupid is flaming fast and furious, flowing down the sides of the volcanoes of stupid spewing forth lots of heat, until the lava of stupid is finally lapping at the last walls defending rational discourse over what is a very difficult issue, both in terms of science, medicine, and policy. In fact, some of the attacks on the new guidelines carry distinct echoes of the same rhetorical techniques of Mike Adams and Joe Mercola. They have been truly painful to read, so full of neuron-necrosing nonsense that I wonder if those conspiracy theorists in tin foil hats might have a point, even though I realize that mere tinfoil will not stop such powerful waves of stupid. Worse, a lot of the press coverage has given free rein to the very same sorts of flaws that so irritate me in the coverage of alternative medicine.

Let me just say right now that I am more forgiving of the press coverage that emphasizes anecdotes over data, stories like this one, which follows a pattern that I’ve seen emerging in the coverage of this story, namely the highlighting of an anecdote of a woman under 50 (or even under 40) who had a breast cancer that was detected either by screening mammography or by self breast examination. Another example is this story. This is lazy journalism at best, where finding the “human interest” angle trumps a science-based discussion of the pros and cons of the new recommendations, what they mean to women, and how they might be applied. It’s the triumph of pure emotion over science. Meanwhile, Congress is getting involved, specifically Rep. Debbie Wasserman Schultz (D-FL), who is threatening to hold Congressional hearings on the matter. (Now there‘s something that’ll shed a lot of light on the science!) Wasserman is a breast cancer survivor; so I can understand her emotional investment in the issue. I can understand the emotional involvement of anyone who’s life has been touched by cancer. Unfortunately, she’s just plain misguided to try to meddle in the development of science-based medical guidelines this way. Her activities are far more likely to interfere with the scientific debate that must occur now regarding screening than they are to facilitate a new scientific consensus based on the strongest data available.

I’ve made my position clear on the new guidelines. They are imperfect and most definitely do not mean that women under 50 should not be screened. Rather, they will most likely serve as reasonable, albeit flawed, starting point for a debate that has been brewing for the last several years as more and more studies have questioned how beneficial screening mammography is for younger women relative to its risks and documented the problems of overdiagnosis and overtreatment. I’ve also pointed out how I know that women will be confused by this change. In fact, if anything failure to communicate such a monumental change in recommendations in a manner that would mitigate some of this controversy is clearly the USPSTF’s biggest failing in the matter. The task force did an absolutely execrable job of laying the groundwork for its announcement, so that it didn’t appear to come out of nowhere. Even so, as I said before, an update of our screening guidelines was expected, and there is much to discuss. However, there is a relentless drumbeat of attack that is not based on science and strikes me as knee jerk. Some of it is downright idiotic; there’s just no other way to put it. I feel obligated to address it because, as a skeptic, I find such bad arguments and misinformation an offense to my intelligence.

Overall, the idiocy falls into three general categories:

1. The misogyny gambit

A disturbing tack being taken towards the guidelines is the misguided urge to cry, “Misogyny!” No, I’m not saying that there hasn’t been misogyny issuing from the government and other regulatory and academic bodies over women’s health before. There’s been a fairly long history of that, and we are only starting to overcome it. I’m just saying that this isn’t one of those times. The problem with this gambit is that those invoking it jump on news reports about the task force report without actually having read the report. For example, Feministing described the guidelines thusly:

New patronizing guidelines for mammograms have been implemented by a government task force, recommending that women over 40 shouldn’t get routine mammograms because of certain risks like women’s “anxiety.”

Bridget Crawford at Feminist Law Professors writes:

The government task force’s reasoning? Because the “anxieties” caused by mammography, false positives and biopsies do not decrease mortality.

If the federal government is so concerned about women’s anxieties, how about more jobs, affordable child care, lower tax rates, clean air to breathe, and an end to discrimination?

I can control my own anxiety about having my breast squished by a mammography machine, thank you.

To which a commenter named CD Dorsey responded:

Just who is this government task force? Probably a bunch of men… Why havent they given the people an updated stating that men should only be screened for testicular cancer when they turn 50?

I won’t bother to point out the ignorance of cancer biology that the above comment reveals unless you really want me to. Suffice it to say: They’re entirely different diseases and not comparable as far as screening goes. I’d also point out that science-based recommendations for screening for prostate cancer suggested scaling back PSA screening long before these mammography guidelines were published. In fact, for most men over 50, routine PSA screening is no longer recommended. Clearly, medicine hates men.

So that I don’t have to (much), the ever inimitably skeptical Skepchick slapped down these knee-jerk examples of such accusations, pointing out that the new guidelines are not “patronizing” in the least. Bridget might have had a point if anxiety and psychological distress due to false positives were actually the primary reasons that the USPSTF made the recommendations that it did. They weren’t. In fact, mentions of psychological distress were actually few and definitely not the primary concern in drafting the new guidelines. The harm from overdiagnosis and overtreatment relative to the benefit of early detection was the primary evidence used. Bridget clearly didn’t bother to read the actual guidelines and relied on news stories that played up the “anxiety” angle, probably because either the reporter didn’t understand the concepts of overdiagnosis and overtreatment or didn’t think readers could understand the concepts. I must admit that I, too, cringed a bit reading some of these stories. However, whenever I read a news account of report or paper and want to blog about it, the very first thing I do is to go to the primary source to read the actual document. That’s Blogging 101. Moreover, the supporting article containing the models used to determine harms under various screening regimens doesn’t even mention psychological harms. Lots of mentions of overdiagnosis, extra testing, and more biopsies, but little or no mention of psychological harms.

Whatever problems I have with these new guidelines, misogyny is not one of them. In fact, the guidelines explicitly state:

The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.

And:

The Task Force encourages individualized, informed decision making about when to start mammography screening.

And:

The American College of Physicians recommended in 2007 that screening mammography decisions in women aged 40 to 49 years should be based on individualized assessment of risk for breast cancer; that clinicians should inform women aged 40 to 49 years about the potential benefits and harms of screening mammography; and that clinicians should base screening mammography decisions on benefits and harms of screening, as well as on a woman’s preferences and breast cancer risk profile.

Whatever their debatability from a scientific viewpoint, if anything the new USPSTF guidelines are arguably less “patronizing” than some of the old guidelines in that they emphasize far more strongly that screening should be a decision to be made collaboratively between a woman and her physician. Even though I have some problems with the guidelines and don’t think that they should mean that women shouldn’t be screened between the ages of 40 and 49, I do like their placing more emphasis on informed consent and collaborative decision making for women regarding screening. The charge of “patronizing” is just plain misguided.

2. We’re going to turn into a Third World country with women showing up with big nasty incurable cancers.

Another seriously deluded attack (not to mention a form of “slippery slope” fallacy) is the overblown expression of fear that, if these new guidelines were to take hold, American women would be relegated to the same status with regard to breast cancer screening as sub-Saharan Africa. No, really. There are people out there saying that, some of them even doctors! Here are some examples:

We believe these recommendations effectively turn back the clock to pre-mammography days by making the diagnosis of breast cancer occur only when the tumor is large enough to be felt on a physical exam. The Society will continue to advocate for routine annual mammography screening for all women beginning at age 40. Mammography screening reduces breast cancer mortality and saves lives. (American Society of Breast Surgeons)

That’s the one that irritated me enough to write a complaint to the ASBS, but it’s mild in comparison to some other statements I’ve seen, for example, the American College of Radiology:

“The USPSTF recommendations are a step backward and represent a significant harm to women’s health. To tell women they should not get regular mammograms starting at 40 when this approach has overwhelmingly been shown to save lives is shocking. At least 40 percent of the patient years of life saved by mammographic screening are of women aged 40-49. These recommendations are inconsistent with current science and apparently have been developed in an attempt to reduce costs. Unfortunately, many women may pay for this unsound approach with their lives,” said W. Phil Evans, M.D., FACR, president of the Society of Breast Imaging (SBI).

[…]

“I am deeply concerned about the actions of the USPSTF in severely limiting screening for breast cancer. These recommendations, in combination with recent CMS imaging cuts, jeopardize access to both long proven and cutting-edge diagnostic imaging technologies. Government policy makers need to consider the consequences of such decisions. I can’t help but think that we are moving toward a new health care rationing policy that will turn back the clock on medicine for decades and needlessly reverse advances in cancer detection that have saved countless lives,” said James H. Thrall, M.D., FACR, chair of the American College of Radiology Board of Chancellors.

Truly despicable. Lots of heat, but no light. But this sort of fear mongering is only warming up compared to others, for instance, Anthony Elias, MD Martha Cannon Dear Professor of Medicine, Medical Director, Breast & Sarcoma Programs, Associate Director; Cancer Center for Clinical Sciences, University of Colorado Denver School of Medicine:

This is quite disturbing and I fear I will be busier than ever caring for incurable neglected breast cancers similar to what happens in Africa, Southeast Asia and China.

Wow. Just wow. I guess that means that Canada is just like Africa, Southeast Asia, or China. Europe, too. After all, Canada and much of Europe recommend screening protocols much like what the USPSTF recommends. I guess that means they must have most of their women with breast cancer showing up with big, neglected cancers instead of mammographically-detected cancers. Those bastards! We don’t want to be like them! (As an aside, let me point out that I rather like Australia’s approach, which appears to be basically a fusion between what we in the U.S. do and what most of Europe does. In Australia, screening is still recommended to start at age 50 but women from 40 to 49 can still have mammographic screening paid for if they wish to be screened earlier.) Responses like this reveal an immense chauvinism, at least to me. It’s assumed that the American way must be the superior way. It may be, but I prefer to look at the evidence. Oh, and Canada and Europe must be hopelessly misogynistic, per gambit #1 above.

Some of the responses I’ve seen also appear to reveal a disturbingly shallow understanding of screening and cancer biology. I have yet to see anyone actually mention lead time bias, length bias, or the Will Rogers effect all incredibly important concepts in screening that suggest why early detection does not always save lives and why the detection of more and more early tumors may give the appearance of improving survival without actually improving it as much as we think. Again, something about these guidelines has made physicians who should know better either forget or ignore everything they should know about cancer biology and screening.

But these previous two gambits pale in comparison to the next gambit.

3. Obama’s settin’ up death panels to kill grandma

Like an undead zombie that just won’t stay dead, the difference being that even if you shoot it in the head it keeps getting up again, the “death panel” lie keeps shambling on, to eat the brains of many a pundit and make them just as ignorant as Sarah Palin, the populizer of this myth. The timing of the USPSTF’s recommendations, released right in the middle of a major political battle over reforming our health insurance system and providing a government-funded option to insure the uninsured, is very unfortunate in that it’s given free rein to conspiracy theorists, the wildest of whom think that the USPSTF’s part of a plot by the government and the cleverer of whom see it as some insidious infiltration of some sort of vile health care rationing. Here are some examples:

Kimberly Morin, Obama’s Breast Cancer Panel is a true ‘Death Panel’ for American women:

Why has this recommendation come about now? Could it have anything to do with the public option that is now on the table and this is a pre-cursor to the rationing that will most definitely ensue as a result of that public option? Why would this panel make these recommendations now after so many years? If you take a look at who the panel is made up of you will see not one breast cancer expert and interestingly these recommendations are very similar to the guidelines that are currently in place in Canada. Obama owns this report. These recommendations are coming under HIS Administration. Obama’s Breast Cancer Panel is truly a ‘Death Panel’ for American women.

I’m tellin’ ya, it’s teh Socialism! It’s obvious, given that these recommendations are much like those of…Canada! Oh noes! It’s a conspiracy! Damn that Obama! See:

What a difference six months — and a health-care overhaul proposal — can make! Just six months ago, the U.S Preventive Services Task Force, which works within the Department of Health and Human Services as a “best practice” panel on prevention, sounded a warning signal over a slight decline in annual mammograms among women in their 40s. In fact, they warned women of this age bracket that they could be risking their lives if they didn’t get the annual preventive exam

Uh, no. If you go to the primary source, you’ll see that the USPSTF was mentioned but only in the context of describing its previous guidelines before this update. In reality it was not the USPSTF that sounded the alarm but the CDC and the NIH:

A Centers for Disease Control and Prevention study published in February noted a slight decline in the proportion of women having annual mammograms in just about every state, including Maryland and Virginia, as well as in the District.

The drop is so small, that researchers hesitate to call it a trend; they call it a “declining tendency.” But it echoes similar findings in recent years. A National Institutes of Health study published in 2007 found that while the percentage of women 40 and older having yearly mammograms grew steadily between 1987 and 2000, those rates leveled off for three years and then declined. “The 2010 target for all women, 70 percent, was met in 2000, but the proportion fell to 66 percent in 2005,” says Stephen Taplin, a senior scientist at the National Cancer Institute.

Ed Morrissey, living up to his blog’s name Hot Air, blathered on:

What changed in six months to change the USPSTF from a sky-is-falling hysteric on a 1% decline in testing to Emily Litella? If the administration gets its way, the government will be paying for a lot more of these exams when ObamaCare passes. That will put a serious strain on resources, especially since many of the providers will look to avoid dealing with government-managed care and its poor compensation rates.

The motivation for HHS will be to cut costs, not to save lives. The sudden reversal in six months of the USPSTF, especially after it made such a stink over a relatively minor decline in screening, certainly makes it appear that they have other priorities than life-saving in mind here.

Funny, but the U.S. Department of Health and Human Services Secretary Kathleen Sebillius just issued a press release that dissed the new guidelines. My cancer center e-mailed it to everyone here yesterday:

“There is no question that the U.S. Preventive Services Task Force Recommendations have caused a great deal of confusion and worry among women and their families across this country. I want to address that confusion head on. The U.S. Preventive Task Force is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy and they don’t determine what services are covered by the federal government.

“There has been debate in this country for years about the age at which routine screening mammograms should begin, and how often they should be given. The Task Force has presented some new evidence for consideration but our policies remain unchanged. Indeed, I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action.

“What is clear is that there is a great need for more evidence, more research and more scientific innovation to help women prevent, detect, and fight breast cancer, the second leading cause of cancer deaths among women.

“My message to women is simple. Mammograms have always been an important life-saving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years – talk to your doctor about your individual history, ask questions, and make the decision that is right for you.”

Damn, that Obama Administration is clever! The Secretary of HHS, the government agency that would be most empowered by any health care reform, slapped down the USPSTF! Of course, the USPSTF is not even a government agency:

The U.S. Preventive Services Task Force (USPSTF), first convened by the U.S. Public Health Service in 1984, and since 1998 sponsored by the Agency for Healthcare Research and Quality (AHRQ), is the leading independent panel of private-sector experts in prevention and primary care. The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the “gold standard” for clinical preventive services.

The mission of the USPSTF is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care.

Again, I blame the USPSTF for its horribly botched communication of its recommendations. True, there would still be cranks out there, but if the USPSTF had been better at laying the groundwork for these changes, at least the idiocy level of the responses might have been lowered.

The undead beast continues to lumber on, though. In fact, it shows up in places where you wouldn’t necessarily expect it. At least, I wouldn’t have. Indeed, it can eat the brains of bloggers that I used to consider fairly reasonable, creating a new zombie. In this case, though, the new “death panel” zombies are rather like the running zombies in 28 Days Later, not the shambling, dripping, drooling zombies of yore. But they’re just as relentless. He’s the new, improved, cleverer zombie, like the ones in The Return of the Living Dead who, after feasting on the brains of paramedics and then later cops, picked up the radio from their car and asked the dispatcher to send more paramedics and cops. But at the heart, the zombie lie continues on, eating brains and reducing the level of debate from the merits of science to raw emotions manipulated by fear of government.

However, as this post has gotten too long and the particular zombie I have in mind has a post that is long enough to require a separate post to fisk it; you’ll have to wait until my next post to find out of whom I speak.

Comments

  1. #1 T. Bruce McNeely
    November 19, 2009

    The task force did an absolutely execrable job of laying the groundwork for tits announcement,

    BWAHAHAHAHA!!!!

    Best typo ever!

  2. #2 Ramel
    November 19, 2009

    Like an undead zombie that just won’t stay dead, the difference being that even if you shoot it in the head it keeps getting up again

    Well there’s your problem, when the zombies have shit for brains you need to shoot them in the arse.

  3. #3 Katharine
    November 19, 2009

    This is just one of the things that happens when most of the surrounding population in the United States has shit for brains when it comes to science.

    I lament the ignorance of the people around me.

    Scandinavian and Asian countries have it right: most of their citizenry values the sciences, whereas many of the idiots surrounding me don’t.

  4. #4 James Sweet
    November 19, 2009

    There was an article in the Sunday NYT by the congressman who inserted the “death panel” provision in the healthcare bill, and his actual intentions. It was really depressing…

  5. #5 PeterD
    November 19, 2009

    3. Obama’s settin’ up death panels to kill grandma.

    That’s a low blow considering the task force was put in place by the previous administration.

  6. #6 Repairman Nick
    November 19, 2009

    I love the fact that you distinguish amongst different varieties of the walking undead. Your attention to detail is truly commendable.

  7. #7 Pablo
    November 19, 2009

    One of the backlashes I have heard against the new suggestions is that “well who doesn’t have breast cancer _somewhere_ in their family”? I expect what we are going to see is that doctors are going to recommend screenings based on the “risk factor” that your grandfather’s second cousin had breast cancer, and therefore it is in your family.

    As I always tell my wife, if first cousins health problems were a risk factor, I would be in serious trouble. I have first cousins who have colon cancer, and who have died from stomach cancer and strokes. Does that put me at risk for these? Possibly, but not likely. When you have 125 first cousins ranging in age from 30 to 65, it is not unusual to expect that there are going to be some issues.

  8. #8 Andreas Johansson
    November 19, 2009

    Scandinavian and Asian countries have it right: most of their citizenry values the sciences, whereas many of the idiots surrounding me don’t.

    Most Scandinavians see the sciences rather like they see classical art – they approve, abstractly, of them, but have little personal interest in or understanding of them.

    (Despite my best intentions, in a discussion y’dy about vaccination I found myself wishing people would be more blindly accepting of authority, because independent thinking does not necessarily lead to pretty results when the “facts” one is basing one’s independent thinking on are half-understood at best and plain wrong at worst.)

  9. #9 T. Bruce McNeely
    November 19, 2009

    So the controversy is about guidelines that are already in place in Canada?
    You guys have known about our Death Panels for years and have said absolutely nothing?

    WHY DO YOU HATE US CANADIANS?????

  10. #10 Pablo
    November 19, 2009

    WHY DO YOU HATE US CANADIANS?????

    Do you want a list or something?

    1) You say “oot” instead of “out”
    2) A tuque? What’s the deal with that?

  11. #11 Pable
    November 19, 2009

    I should mention, that’s just the start

    (although Canada did give serve as an inspiration for Strange Brew, which gave one the best movie lines in all of history, “I am your father, Luke. Join the Dark Side of the Force, you ‘knob”)

  12. #12 JohnV
    November 19, 2009

    funny story about tuques. growing up in new york, i was aware that that was the proper name for a “wool hat” or “winter hat”. i also knew that the proper name for that piece of wood you use to ride along in the snow was a toboggan.

    i then go to grad school in virginia and spend the next 5.5 years correcting people who refer to tuques as toboggans. and thus, the basis for my hatred of the south.

  13. #13 Sir Eccles
    November 19, 2009

    Can’t they just go to the Cancer Treatment Centers of America and let Peggy check the date stamp on their feet?

    (been seeing that ad too much on TV recently)

  14. #14 MaryL
    November 19, 2009

    Yeah, the guideline here in Canada is that breast cancer screenings start for low-risk groups at 50, as does colon cancer screening. But my sister and I started screening for both in our 40s because we had aunts on both sides of the family with breast cancer, and all kinds of digestive system cancer run in the family, although no colon cancer (yet). I guess the Ontario death panels are just that inefficient that we were able to get away with this.

  15. #15 PeterD
    November 19, 2009

    The task force did an absolutely execrable job of laying the groundwork for its announcement, so that it didn’t appear to come out of nowhere.

    A couple of nights, Anderscon Cooper had Dr. Kimberly Gregory, a member of the task force, and Dr. Danile Kopans, professor of radiology at Harvard Med. School, on his show to discuss the new recommendations. I must say that Dr. Gregory, when questioned by the host, looked like—please pardon the cliche—a dear caught in headlights. She was inarticulate, unprepared, and barely able to complete her sentences (when she wasn’t screwing up the number of the verb!). Damn, as I watched this I couldn’t help thinking about how the hell she was ever chosen to be on the task force. Needless to say, Dr. Kopans had a field day with her.

    Is it any wonder that people are still confused with the new recommendations?

  16. #16 Joseph C.
    November 19, 2009

    Most Scandinavians see the sciences rather like they see classical art – they approve, abstractly, of them, but have little personal interest in or understanding of them.

    Yeah, there is plenty of anti-vax sentiment in Scandinavia. See the comments on this article:

    http://www.thelocal.se/23332/20091118/

    If you search through that site, you’ll notice anti-vax comments on every article about H1N1 or vaccines.

    Moral of the story: Idiots are everywhere.

  17. #17 Geoff
    November 19, 2009

    May also be worthwhile to point out that 12 of the 16 board members were seated before George Bush took office. The remaining 4 were elected before he left office. Clearly Obama has had this in the works for a long time.

  18. #18 PeterD
    November 19, 2009

    An edit button would be nice. :)

    “A couple of nights ago” not “A couple of nights”

    “Dr. Daniel Kopans” not “Dr. Danile Kopans”

  19. #19 T.Bruce McNeely
    November 19, 2009

    May also be worthwhile to point out that 12 of the 16 board members were seated before George Bush took office. The remaining 4 were elected before he left office. Clearly Obama has had this in the works for a long time.

    That’s nothing for a guy who can travel back in time and insert fake birth annouincements in Honolulu newspapers.

  20. #20 LK PhD
    November 19, 2009

    Good assessment of the response. I would add a 4th category – those who have tried to exploit the panel’s recommendations to justify more “individualized” decision making on vaccination. I think you know who I’m talking about… Funny how they’ll agree with a group of doctors about some things.

  21. #21 James Sweet
    November 19, 2009

    The reason our death panels will never work is because you need to go to a single payer system in order to enforce them. The public option is not good enough. With everyone seeking out a different insurance provider, how will we make sure that those condemned by the death panels are actually executed? I mean, if they get a negative ruling by one death panel, they could just switch insurance providers.

    Nope, Canada’s death panels may be a model for the rest of the world, but we’ll never come close to achieving the kind of slaughter they have.

  22. #22 KeithB
    November 19, 2009

    Hmm, I wonder if the American College of Radiology has a conflict of interest here. They certainly wouldn’t be against this because it may reduce the number of mammograms, would they?

  23. #23 Software Engineer
    November 19, 2009

    While I appreciate a good hating on HotAir and even Feministing, the exact same points of view (rationing and misogyny) were expressed by TalkingStick (self-identified oncologist) at FireDogLake describing this as having nothing to do with science and being an business model based medicine and by Arthur Caplan (world famous uber medical ethicist) on the Diane Rehm Show stating that medicine and society hates women, values them less, and these recommendations are both misogynistic as well as unethical.

  24. #24 Pablo
    November 19, 2009

    Hmm, I wonder if the American College of Radiology has a conflict of interest here. They certainly wouldn’t be against this because it may reduce the number of mammograms, would they?

    To be fair, though, even if this is true, it does not necessarily mean something sinister or evil. It may just be that the American College of Radiology thinks they have the best approach for the problem. Of course they are going to fight it, not because of money, but because of arrogance (for lack of a better word). They want to push for more applications of radiology, as many as possible, to validate their field.

  25. #25 Orac
    November 19, 2009

    …by Arthur Caplan (world famous uber medical ethicist) on the Diane Rehm Show stating that medicine and society hates women, values them less, and these recommendations are both misogynistic as well as unethical.

    Does that mean he thinks that Canada, Australia, and Europe are all misogynistic and unethical?

    As much as I’ve admired Art Caplan over the years, if he truly said that, he had momentary brain fart. I’d like to hear what he said in context, because the reports I’m getting from his appearance on the Diane Rehm Show sound really, really unlike him.

  26. #26 muteKi
    November 19, 2009

    Death panels. Just the outcry against them on their own amuses me, at least in terms of the current health care debate.

    Sure is a good thing that we don’t have suits in offices trying to save money for the insurance companies by withholding payment for certain services they don’t like or feel are unnecessary, or even preventing people from getting insured at all.

    Oh, right. That’s what we’re trying to fix isn’t it. Hm, well, in that case then, I guess it’s a good thing that it’s being done by a private for-profit company rather than the government. After all, companies like Lehman Brothers’ only had their customers best interests at heart when they…

    Oh, right.

  27. #27 andrew
    November 19, 2009

    “Why has this recommendation come about now? Could it have anything to do with the public option that is now on the table and this is a pre-cursor to the rationing that will most definitely ensue as a result of that public option? ”
    I am sorry to be the bearer of bad news for many Americans but ALL health care is rationed, The question is how it is to be rationed, If it is free at the point of consumption then the demand is infinite (The demand for a free good is infinite).As resources are finite the infinite demand has to be controlled i.e. rationed. In the NHS this is either covertly via post code(read Zipcode) or overtly by NICE, in the US it appears to be by cash resources or insurance(read cash). It is imperative that the mode of retioning be done in free and open discussion given the resource constraints available. The first step is to recognise the need and set parameters for treatment- this is what USPTF appears to be doing. The NHS is based in theory on medical need with expenditures set centrally, with tax besed funding, i.e. a Socialist approach, this is open to challange but if it is to be challenged please explain the problems with a socialist approach calmly and coherently not with invective.(and yes I know we have serious problems with the NHS)
    OOPS I am off topic

  28. #28 HanRy
    November 19, 2009

    thanks.

  29. #29 Scott
    November 19, 2009

    @27:

    Very well put, andrew. “Rationing” is, always has been, and always will be a fact. Denying that fact really just means denying that it’s worth discussing how it’s done, and on what basis.

  30. #30 Software Engineer
    November 19, 2009

    I’m running to a doctor’s appointment, but I think yesterday’s dr show is available via mp3. When I get back I’ll see if that’s true and try to point into the stream where he said that (IIRC it was toward the end.)

  31. #31 Azkyroth
    November 19, 2009

    I can’t speak to the rest, but the increasing prevalence of “spray-and-pray” use of accusations of “misogyny” and a “shoot first, acknowledge questions never” attitude among people who ought to know better extends far beyond the cancer debate, as certain of your SciBlings are occasionally so kinds as to demonstrate. This is becoming a real problem among progressives; I guess any movement with a prescriptive component can, and given enough time will, eventually be co-opted by bullies for the purpose of “personal power projection,” but I’m not sure what to do about it. The people trying to dredge this specter up in the cancer debate, though, clearly don’t have enough to do.

  32. #32 KeithB
    November 19, 2009

    Pablo @ 24:
    “To be fair, though, even if this is true, it does not necessarily mean something sinister or evil. ”

    I don’t think they are sinister or evil, just greedy.

    Isn’t that one of the reasons for professonal organazations? To advocate for the stuff like more money so that all the individual members can have some plausible deniability?

  33. #33 rrt
    November 19, 2009

    Hiya Orac. The Diane Rehm MP3 is available now. I believe I’ve listened to the whole segment Caplan is in, and if so, then you’re right: His comments are being misinterpreted.

    The file can be found here:

    http://wamu.org/programs/dr/09/11/18.php#28909

    Caplan comes in at about 36:00, and I think the relevant comment starts at 46:10, in response to an angry caller. My effort at a transcript:

    “I’ll concede this: I think that the caller’s right, there has been sexism in medicine. It has been true historically that women’s lives, for different diseases, have not been valued the same way–more effort in heart disease in men than heart disease in women would be an example. So, there is some bias, I think it does show. Nevertheless, I think from the point of view of ethics, once you commit and say ‘we’re gonna cover this,’ even though data starts to show up saying ‘I dunno, it’s not as good as we’d hoped,’ it’s very hard to take something away.”

    In my opinion, Caplan is saying “well of course there’s gender bias in medicine.” It’s not a condemnation of the panel’s recommendation as biased, and the context of the show makes it pretty darn clear his views hew close to yours. His main point throughout the show is that it’s going to be very, very hard to roll back any screening recommendations and that we need to take this as a lesson (with, I think, the implication that they should back off.)

  34. #34 James Sweet
    November 19, 2009

    Hm, well, in that case then, I guess it’s a good thing that it’s being done by a private for-profit company rather than the government. After all, companies like Lehman Brothers’ only had their customers best interests at heart when they…

    Oh, right.

    It’s worse than that. At least when it comes to Lehman Bros., for the most part, what’s good for the bank is good for the consumers as well (not universally of course, but their interests align more often than not: Both want to see investments yield big returns). When it comes to insurance — and kind of insurance, really, not just health insurance — what is good for the insurer is the exact OPPOSITE of what is good for the insured.

    This is particularly bad in the case of health insurance, where the majority of people have no (or only limited) choice in providers. At least for, say, auto insurance, if Company X pursues that bottom line too aggressively by denying too many claims, it’s conceivable they could get a reputation and lose customers. Doesn’t work that way for health insurance.

    Unless you really believe that, if an insurance company starts denying too many claims, then those employers who use that insurance company will start to lose employees at a rate high enough that they will push back on the insurance company and/or switch to a different one. But I might call that “Rube Goldberg economics.” Ain’t gonna work that way.

    I’m a huge fan of capitalism and the corporate model in that it represents a tool that will find the best way of maximizing short-term profits in a ridiculously short amount of time. If you can craft legislation to align short-term profit incentives with long-term consumer benefit — which is possibly in many industries — then you are not going to beat that level of efficiency.

    In health insurance, that’s just goddamn impossible. The natural short-term profit incentives are diametrically opposed to long-term consumer benefit (the former is to pay as few claims as possible, and to focus what claims are paid on things that superficially make customers complacent; the latter is to pay out claims based on what will keep the population healthiest) and there is just no good way of bringing them back in line.

  35. #35 Joseph C.
    November 19, 2009

    Unless you really believe that, if an insurance company starts denying too many claims, then those employers who use that insurance company will start to lose employees at a rate high enough that they will push back on the insurance company and/or switch to a different one.

    Really the entire employer-sponsored system is broken. There is basically no consumer choice under it. You might see more efficiencies if individuals were given the same tax break to buy insurance plans that employers are. Then you could truly fire crappy insurance companies.

    Also, our habit of using insurance to pay for everything health-related, even minor things, makes it massively wasteful because we’re not spending our own money.

    Seriously, health care is an oddity among industries. I remember trying to call various dentists in my town a few years ago just to compare prices. Basically, I thought my dentist was overcharging me and I wanted to compare. This practice was apparently non-standard and the response I usually got was “we don’t give out prices over the phone”.

  36. #36 Software Engineer
    November 19, 2009

    I went back and listened again, thanks to rrt for the precise moment when Caplan comes in. I think Caplan was unclear and counterproductive, and the whole DR Show was all about the misogyny, that came through many times over.

    Here is my lousy transcript/paraphrase of what happened:

    37:00 Caplan says he fears how “this” (presumably controversy over recommendations) will impact evidence based medicine which he supports, but also emphasizes how unethical it would be to take previous treatments away, as well as mentions the rights of patients to even marginal treatments.

    42:14 Caplan supports the resolution, but lesson is we can’t go backwards and take things away from people

    At some point he says the panel’s decision was not about the money…. But then at

    43:44 Caplan agrees it’s about economics and how best to spend the money

    44:34 Diane Rehm asks: How many deaths are acceptable vs. cost of mammography? Caplan answers (or fudges): It’s already been funded, it’s unethical to take the benefit away

    45:25 (Angry (elderly?)) Woman Caller in Ft. Worth Texas: This is an assault on women. If this study had been on prostate cancer, there would be an uproar! (Even Diane Rehm points out, there IS an uproar, (apparently caller means if it were men, the uproar would be taken seriously.)

    46:00 Caplan: There has been a similar study on but prostate cancer is still covered (even though near as I can tell the panel is not about not covering mammography, it’s about when mammography is indicated). Caplan continues: There has been sexism in medicine, women’s lives are valued less, there is some bias, but this is an ethics question, we can’t take benefit away, it’s unethical.

    So Caplan does seem to:
    a) support recommendation
    b) understand the problems of overdiagnosis/overtreatment
    c) agree that there’s lots of misogyny in medicine
    d) deny this is about money, agree it’s about economics
    e) go back over and over to how unethical it is to remove treatments from patients.

  37. #37 Karl Withakay
    November 19, 2009

    @andrew 27

    “The demand for a free good is infinite”

    I have to disagree with you there; there has to be some perceived utility of the good for their to be demand for the good.

    I’ll give a few examples that contradict that assertion.

    – I have a friend in a local band, and have attended many of his shows. I frequently see local bands attempting to literally give their CD’s away for free, and not be successful.

    – I have seen items sit unclaimed on the curb with the word “FREE” written on them. Infinite demand would imply everybody on the planet would try to acquire it.

    – Access to most web sites is free, including my blog, but demand to view those sites and consume their content is not infinite, as my blog stats indicate.

    There is also the point of zero marginal utility. At this point, you don’t need or want any more of a good or service, regardless of how low the price on it is.

    Very little in this universe is literally infinite.

  38. #38 storkdok
    November 19, 2009

    @Pablo “When you have 125 first cousins ranging in age from 30 to 65, it is not unusual to expect that there are going to be some issues.”

    I’ll bite. How many siblings do your parents have? I’ve got 15 first cousins.

  39. #39 Joseph C.
    November 19, 2009

    Very little in this universe is literally infinite.

    Except the stupid.

  40. #40 LW
    November 19, 2009

    Even the stupid isn’t infinite. Look how repetitious and boring Orac’s trolls have gotten. If the stupid were infinite, they’d at least be stupid in new ways each time.

  41. #41 Joseph C.
    November 19, 2009

    Even the stupid isn’t infinite. Look how repetitious and boring Orac’s trolls have gotten. If the stupid were infinite, they’d at least be stupid in new ways each time.

    But they won’t STFU. And that is a form of infinity.

  42. #42 Denice Walter
    November 19, 2009

    I submit that the stupid *is* infinite: exhibit A. Mike Adams;NaturalNews,11-19-09-“Cancer industry desperately needs mammograms to recruit patients and generate repeat business”. exhibit B.Sarah Palin’s new book. I rest my case.

  43. #43 Joseph C.
    November 19, 2009

    A. Mike Adams;NaturalNews,11-19-09-“Cancer industry desperately needs mammograms to recruit patients and generate repeat business”.

    Damn you! I had been staying away from that site for several months, but you made me go back.

    Yep, Mike Adams is as dumb as ever.

  44. #44 DLC
    November 19, 2009

    I wonder, if it were some other cancer if changing the screening recommendation would be as touchy a subject.
    Well, it isn’t, and trying to make comparisons isn’t really helpful.

  45. #45 katydid13
    November 19, 2009

    As a professional policy wonk who writes the Congressional testimony others read at hearings, I have to say that your comments on the role of Congressional hearings on such a subject was spot on. Really there is very little that is scarier than when Congress decides to talk science.

  46. #46 Pablo
    November 19, 2009

    storkdok:

    I’ll bite. How many siblings do your parents have? I’ve got 15 first cousins.

    Dad was 1 of 13, mom was 1 of 12, I think, although one of my dad’s brothers is single and childless (and 85), and one of mom’s brothers drowned when he was 12.

    I should note that the 125 was rounded. The last time I tried to count, I think I got 127, although I don’t remember if that was total in the generation or cousins. And as I noted, at least two have died.

    In terms of age, I am the 6th or 7th youngest of the bunch.

    A few months ago, I was reading about the oldest woman alive. She had something like 25 grandkids, 50 great-grand kids, and 5 great-great-grandchildren. She was 110. If my grandmothers were still alive, they would be about the same age as her. They would each have about 60 grandchildren, probably 250 great-grandchildren, and somewhere on the order of 50 great-great grandchildren, with probably 3 – 5 due at any one time (my neices and nephews are currently in childbearing years and are active)

  47. #47 Jane
    November 19, 2009

    I think #4 should be: The insurance companies did this. Apparently their reach extends beyond the US to infiltrate the government-run health care systems in Canada, Europe, and Australia, and they’ve been working this gambit for years just to deny mammography for 30-somethings in the US who have breast cancer.

    The complaints about the quality of life results are perplexing. Quality of life questionnaires from the EQ-5D to the SF-36 assess anxiety levels in studies of medical interventions and these questions are asked of men in other studies. The commenting from the guideline Task Force appears to take into account results from such questionnaires in studies of mammography screening. This is self-reported data from participants in the studies, not some evil conspiracy to make women look hysterical and weak. I also do not see how saying these new guidelines “confuse” women is any more or less degrading. They appear straightforward to me, and my lady brain isn’t all a flutter with cognitive dissonance, but I don’t feel threatened by the assertion that some women might be confused.

    I would like to see more attention given to absolute risk, as the reliance upon reporting relative risk reductions tends to make for good copy and lots of heat, but I’ve not seen it add to rational discussion outside of journal articles with confidence intervals and p values. To hear some tell it, 15 out of every 100 women between 40-49 will now die of breast cancer because of this recommendation. Attempting to explain is an exercise in futility, because one finds oneself quickly labeled “part of the conspiracy” or “ignorant of the facts.”

    Another point that I don’t connect with is that I should *know* someone who has had or died of breast cancer. Aside from celebrities, I know of one woman, a neighbor from years ago, who was treated for a lump in her 60s. Off the top of my head, I’ve *known* several women or girls who have been killed in car accidents, two homicides, one aortic dissection, two in separate house fires, one osteosarcoma, several suicides, one colon cancer death, two septicemia-related deaths, and several SCDs or MIs. I’m aware breast cancer exists, but it’s not really on my radar to the extent that this recommendation would elicit some visceral reaction. Perhaps that’s why I’m disconnected from the outrage.

    I also don’t feel this reaction bodes well for the push for single-payer health care in the US. I don’t want policy determined by the prevailing levels of marketed political outrage over well considered and measured approaches to public policy recommendations.

  48. #48 Antaeus Feldspar
    November 20, 2009

    Off-topic for this post, sorry, but I felt it had to be shared: the autism cranks have shifted the goalposts yet again and found yet another element of vaccines on which to blame the (non-existent) connection between vaccines and autism. You’ll never guess what it is: gelatin. “Apparently they have found that the gelatin that is prevalent in many of our vaccines, are causing this huge problem. … It seems that since 1979, just prior to the massive continuous rise in autism diagnoses, hydrolyzed gelatin was added to the MMR vaccine as a stabilizer.”

    Unfortunately, the particular screed in which this theory is explicated is currently being served up by Google News as if it were, well, news, even though it’s coming from American Chronicle, a site where the only credentials you need to write is to say “Yes, you can print ads alongside my writing.” The good news is that it’s written by such consummate Kool-Aid drinkers that it reads like a Poe. The warning flags are all over the place. The guy emphasizes several times that the group is “neutral”, “non-conflicted”, “with no ties to the pharmaceutical or mainstream medical industries” (notice that qualifier of “mainstream”) – and then says that they reached their conclusions “with the help of research from Dr. Andrew Wakefield, Dr. Russell Blaylock, Dr. Martha Herbert”! As if Andrew “Let Me Get My Study Population From The Lawyers Along With My Half-Million Pounds” Wakefield wasn’t the poster boy for conflict of interest!

  49. #49 Calli Arcale
    November 20, 2009

    Gelatin? Gelatin?

    *blink blink*

    At least with squalene, it was something most people don’t know about. But gelatin is as familiar as the school cafeteria. I wonder if there is any connection to the animal rights movement in this? They keep trying to demonize gelatin, since most people aren’t aware that it’s an animal product, produced largely in that PETA-horror-show venue, the rendering plant. (You get it mainly by boiling bones and skin. If you’ve ever made soup from a leftover hambone, it’s the gooey clear stuff that ends up floating on the top of the water.)

    *shakes head* That’s just nuts.

  50. #50 Phoenix Woman
    November 20, 2009

    Calli and Antaeus: They’re trying to piggy-back onto this study concerning anaphylactic (allergic) reactions to vaccines containing gelatin, I reckon:

    http://www.medpagetoday.com/MeetingCoverage/ACAAI/16872

  51. #51 T. Bruce McNeely
    November 20, 2009

    Gelatin?

    OMFG!!!! Bill Cosby wants to kill us all!!!

  52. #52 Scott
    November 20, 2009

    Wonder what they’ll pick on next?

  53. #53 Sir Eccles
    November 20, 2009

    Ok, hydrolyzed gelatin. How long until one of the woo merchants misreads that as hydrogenated and decides they are injecting poor innocent children with margarine, zomg the trans fats!!!!!

  54. #54 Calli Arcale
    November 20, 2009

    That makes sense, Phoenix Woman. Well, it makes sense as a motive, anyway. As a conclusion it’s absurd. Most people aren’t allergic to gelatin or Kraft Foods would’ve tanked by now due to their horrible, murderous Jell-O product line.

  55. #55 Vicki
    November 20, 2009

    Anyone who thinks there is infinite demand for a free good or service hasn’t been in a situation where dental services or coverage are free. I used to work someplace that gave us dental insurance as a fringe benefit (no employer contribution). Does anyone seriously think 100% of my coworkers were seeing their dentists as often as recommended?

    Right now, I pay $4.69/month for a plan that covers, among other things, two cleanings a year at no charge to me. Also some number of X-rays at no charge to me, and 80% of the cost of fillings. (They pay less on complicated procedures, and there is an annual maximum benefit. If I need root canal, it will cost me real money.) For comparison, when I was uninsured I paid my dentist $100 for a cleaning and exam. So, if I get my teeth cleaned once per year, and no other dental care, it’s worth my buying the coverage. I suspect that if I were to start asking around, I would find a number of coworkers who didn’t take it because they didn’t expect to use it, and a bunch more who have it, with a vague “in case I need it,” but haven’t been to the dentist in years.

    Dental care is far from the only medical service that people find unpleasant, even while admitting that it’s useful. (Some people who don’t want a flu vaccine feel that way because they’ve had bad reactions in the past. And some people are just afraid of needles.) I have a gym membership. That means my marginal cost per visit is zero: it costs me no more to go three or more times a week than to go once a month. Not many people go to my gym three times a week, and fewer still go every day.

    For that matter, my marginal cost of riding our transit system is zero: since I commute by subway, it makes sense for me to buy the 30-day unlimited pass, instead of paying per trip. I do take some extra trips because of that, including things like hopping on a crosstown bus if one is there. But I don’t wake up on Sunday and think “hey, the bus is free, let’s go for a ride.”

  56. #56 Everbleed
    November 20, 2009

    Orac said:

    “Indeed, the stupid is flaming fast and furious, flowing down the sides of the volcanoes of stupid spewing forth lots of heat, until the lava of stupid is finally lapping at the last walls defending rational discourse over what is a very difficult issue, both in terms of science, medicine, and policy.”

    The above Orac spewed sentence is truly ART.

    I can’t wait to stick it on an email (with appropriate credit of course) and zap something stupid.

    There are few things more beautiful in the Universe than a stunned Orac. I almost find myself wishing for more flows of stupid lava just so Orac can have the inspiration to create his high art.

    Long live Orac. Long live stupid.

    We all desperately need the fun.

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