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Mammography and the “Best Health Care in the World”

Posted by John McDonough  November 26, 2012 09:39 PM

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Whenever critics (like me) assert that the U.S. health care system is worse than mediocre despite spending about 50% more per person than the second most expensive system, counter-critics assert that we do have the best health care system in the world. Their evidence -- the U.S. has the best survival rates for breast and prostate cancer on the planet. That's exhibit A.

What if it's not true?

That is one of the compelling conclusions one may reach from last Thursday's research published in the New England Journal of Medicine: "Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence" by Archie Bleyer, M.D., and H. Gilbert Welch, M.D., M.P.H.:

"Despite substantial increases in the number of cases of early-stage breast cancer detected, screening mammography has only marginally reduced the rate at which women present with advanced cancer. Although it is not certain which women have been affected, the imbalance suggests that there is substantial overdiagnosis, accounting for nearly a third of all newly diagnosed breast cancers, and that screening is having, at best, only a small effect on the rate of death from breast cancer."

Welch also wrote a compelling op-ed, "Cancer Survivor or Victim of Overdiagnosis," in last Thursday's New York Times on his findings.  Here's a key chart from the NEJM article:


women-40+-500x460.png




 The chart shows that despite an explosion in screening for breast cancer and an explosion in diagnosis of early stage breast cancers, the diagnosis of late stage breast cancers has hardly budged since 1976. Here's another important chart from a related article in last week's NEJM, "Clinical Decisions: Mammography Screening for Breast Cancer":

Cancer-aspirin-500x414.png






 So, based on this study's results, screening has almost no impact on the risk of death, only an impact on the likelihood of breast cancer diagnosis.

So it's still true -- the data show that American women who are diagnosed with breast cancer have the best survival rates in the world. It's also true that some experts have referred to these new studies as "junk science."  It's just that it now appears that a large number of these women counted in the survival rates did not really have breast cancer. And that pretty much rescinds the bragging rights.

Back in 2009, when Congress was debating the Affordable Care Act, the U.S. Preventive Services Task Force, an unpaid and volunteer federal panel of physician experts, recommended against routine screening of all women under the age of 50 for breast cancer. The uproar against the recommendations led Congress to include in the text of the ACA a nullification of the Task Force's recommendation.

The evidence keeps growing that the Task Force was correct. When, if ever, will the public catch on? And when will the defenders of U.S. health care as the "best in the world" admit they're wrong? That last one's easy -- never.

This blog is not written or edited by Boston.com or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »

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