As you’re probably well aware, the U.S. Preventive Task Force released new breast cancer screening guidelines last November. And the ensuing furor highlighted a huge issue, one that will only become more and more prominent as America’s health-care delivery system makes its way down the rocky path to reality.
Evidence-based medicine. Remember those words, because you’re going to be hearing them over and over again in the coming months.
So, what is evidence-based medicine – or evidence-based care, or outcomes, or evidence-based anything else?
A simple definition (thanks, Wiki) is that evidence-based medicine is “applying the best available evidence gained from the scientific method to medical decision making.”
In other words, collect data, and use it to make decisions around medical care and treatment.
On the face of it, this process seems to make sense. We do it ourselves every day. For instance, we notice that the intersection of Main and Elm streets is always busy at 5 p.m. Therefore, we avoid that intersection at 5 p.m.
Yes, when the evidence and its interpretation involve simple matters of little import. Not so, when people’s lives are at stake.
In coming to the conclusion that medical care should be delivered in the most efficient, effective way possible, proponents of evidence-based medicine reduce the importance of the human factor. Relying strictly on the statistical analysis of data, they note the following:
•For every 1,000 women receiving a mammogram, 470 women will get a false-alarm call-back, necessitating an additional mammogram or MRI;
•33 of those 470 will receive a biopsy that turns out to be negative;
•For every 1,000 women receiving a mammogram, less than one woman’s life (.7 life) will be saved due to that mammogram having identified breast cancer that was then successfully treated.
Evidence-based medicine would conclude that clearly, this is an awful lot of screening for very little benefit – statistically speaking. With an average cost of $125 per mammogram, you’re already at $125,000 to save .7 life, without even adding in the 33 biopsies and 470 additional screenings.
It’s costing multiple hundreds of thousands of dollars to save less than ¾ of a life. Is this the most efficient, effective way to deliver health care in America?
Absolutely not, proponents of evidence-based medicine argue.
But what would one of these statisticians say if the .7 life saved was that of his wife?
And here, friends, is the heart of the issue – the great divide separating advocates of evidence-based care, and opponents.
The statistics in this mammogram-guideline debate aren’t simply numbers on a sheet of paper. They represent people. Mothers. Wives. Daughters.
That .7 woman is one whose death could create a long-lasting ripple effect, tearing up her family, affecting her community, injuring her workplace… wounding her children irreparably.
That life turns out to be so much greater than .7.
Frankly, I’m still torn on this issue. Our monetary resources in America aren’t limitless. We HAVE to reform health care, lest we bankrupt ourselves as a nation.
On the other hand, my heart won’t let me place a monetary value on anyone’s mother. Call me weak and sentimental (or simply call me human), but I just can’t do it.
What’s the solution? As usual, compromise. Take evidence-based outcomes, but don’t apply them across the board. Dig deeper into the data, deep enough to provide “personalized” conclusions.
In the case of breast cancer, that means that a healthy 40-year-old woman with no family history and no identifiable risk factors, understanding that her risk of developing breast cancer in the next 10 years is very unlikely, might choose to forego an annual mammogram.
It also means that a 25-year-old woman whose mother and sister have both been diagnosed with breast cancer should have access to enough data to assess her personal risk. And be able to choose to have annual mammograms beginning at age 30, understanding that she may very well experience a negative biopsy along the way, as well as anxiety-producing mammogram callbacks.
Responsible personal choice. It’s a hallmark of democracy – and something I fear we might lose, if “head” trumps “heart” in the evidence-based medicine debate.
Published On: February 02, 2010