Medical practices under microscope for effectiveness

Even as the nation wrestles with the proposals for national health care, another battle over how people should be cared for has been joined, symbolized by two medical announcements this past week.

The first was a federal advisory health board's recommendations that women in their 40s no longer should get routine mammograms, unless in an identified risk group - a reversal of current policy which urges yearly exams for all women in their 40s.

The panel said routine mammograms should not start until women reach age 50 and then only every other year instead of the current recommendation of yearly exams. Routine breast self-examinations by women were also ruled not sufficiently effective to continue, another change in policy.

Before the huge controversy over these recommendations could even die down, a new announcement was made at the end of the week that may stir similar reactions. It had been recommended that teenagers and young women get yearly Pap smear tests to help detect cervical cancer.

Now the recommendation from another federal health panel is that Pap smears every other year should begin at age 20 for women and even less frequently for women in their 30s.

These recommendations were based on an analysis of scientific evidence by the health panels to determine the effectiveness of past recommendation in combating cancer. If less frequency in testing was found to be effective, then that was the recommendation.

The problem is that emotion and science don't always correlate, and in this case there are instances of women who fell into the small group of women who were helped by the current guidelines, who feel they would not be alive today were it not for the mammogram they received at a younger age - or the early Pap smear or diligent beast self-exams to find the small lump that was the beginning of breast cancer.

Telling these women that the tests are no longer needed stirs deep emotions that are hard to deflect, even if the hard research data clearly demonstrates that relatively few women - out of all those who are tested - actually benefit from it.

For example, one in around 1,900 women in their 40s benefit from cancer detection with the early mammograms while the remainder are inconvenienced by unnecessary and sometimes painful testing, along with stress from false positive results due to the very imperfect nature of mammograms.

 Is it worth it? To the one woman who benefits, the answer is an emphatic yes. However, looking at it dispassionately - which is what science is about - yields another answer. But telling people to look dispassionately at health care can be a hard sell.

Cancer prevention advocates disagree with the mammogram change. It has been a long struggle to convince women to get these routine exams, and now they are being told it was a mistake. Yet they know some lives have been saved, even if not enough to be considered effective by the panel.

Some doctors have joined in opposing the change. One physician summed up their feelings by saying even if only one woman's life was saved, it was worth all the inconvenience and effort needed to save that life.

That is an understandable reaction from doctors. They have one focus - helping people and saving lives, in some instances no matter what it takes or costs.

But there is a growing recognition, even among doctors, that health care needs to be rational and that there needs to be a balance between too much care and the too little care so that limited health care resources are are used properly and efficiently.

This trend will continue whether a national health care plan is approved or not in Washington because there is no other way to ensure that adequate health care will remain available and affordable for Americans.

Actually, this test of effectiveness already takes place. Health insurance providers - both private and government - evaluate whether procedures are worthwhile, when they should be conducted and for whom and whether the cost will be covered. Those guidelines are part of their reimbursement policies.

The reason for the concern about routine mammograms, for example, is the fear that insurers will decide not to cover them - some already are doing that - if they are not found effective enough.

Nevertheless, "effectiveness" and "medical best practices" will be the bywords in health care in coming years, even if some do not like the idea.

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Terry Ross is director of the Yuma Sun's News and Information Center. E-mail him at tross@yumasun.com or phone him at 539-6870.