Tempest in a C-Cup

The U.S. Preventive Task Force's recent recommendation that women should not begin routine mammograms until age 50 has sparked controversy. "They will increase the number of women dying of breast cancer," said Dr. Bernadine Healy, former director of the National Institutes of Health, on Fox News Sunday. "I'm saying very powerfully ignore them." Dr. Otis Brawley, chief medical officer of the American Cancer Society, said of mammography, "this is one screening test I recommend unequivocally."

As for women themselves, many have reacted angrily. "Whomever thought of this guideline is a boob. No pun intended," read one of the thousands of comments posted on the Internet. The anxiety represents a perfect storm of politics and psychology.

Politics first. The mammography recommendation lands smack in the middle of a roiling health care debate. Bad timing: It makes the guideline look like a cynical move intended to save costs at the expense of lives. The recommendation also foreshadows fears of rationing, a queasy prospect indeed. In some circles, it fuels long-standing suspicions about the medical patriarchy.

What is in the best interest of a population may not be ideal for a specific patient.

Though the Task Force did not consider costs--it weighed only the benefits of frequent screening against the harms of false positives, such as anxiety and unnecessary additional tests, radiation and biopsies--cost consideration is indeed a major part of the larger health care overhaul. This is a why the Obama administration included over $1 billion in the economic stimulus package for comparative effectiveness research.

While such research is not geared specifically to cost savings, if it can demonstrate that two or more medications for, say, schizophrenia are equally beneficial to patients, then the cheaper one should be the drug doctors prescribe first.

From such research will flow recommendations (which could become binding) for scores of procedures from coronary artery bypass surgery, to genetic screening, to the optimal use of medications. If the directives are to cut down or even abandon established practice, they might spark backlash as well.

Let's turn now to the psychology.

In part, the resistance to the new recommendation is the result of honest to goodness confusion: to screen or not to screen. Mixed messages are ricocheting around in the media as groups such as the American Cancer Society, the American College of Radiology and Susan G. Komen for the Cure do not agree with results of the Task Force. "Tens of thousands of lives are being saved by mammography screening, and these idiots want to do away with it," a radiology professor at Harvard Medical School told the Washington Post. If the experts can't agree, how can the public feel reassured?

Also fueling the controversy is the inherent conflict between private health and public health. After all, what is in the best interest of a population may not be ideal for a specific patient.

This tension has long vexed medicine. A classic example is vaccination. One's own child may be healthy enough to fight off, say, measles; if he gets infected, he'll recover and be fine. But the point of mass vaccination is to protect other members of the community who are too frail to tolerate complications should they become infected. So while a given child might not need a vaccine, sound public health practice requires him to have it.

There is yet a more subtle and global dimension to the mammography controversy: the power of natural cognitive biases in how we judge risk. In the words of MIT behavioral scientist Dan Ariely, we are often "predictably irrational." Humans are subject to numerous kinds of distortions in decision making.

The most obvious is the so-called status quo bias. This is a tendency to reject a new paradigm in favor of an established one without considering the merits of the new proposal. This is also called the Semmelweis reflex, named after a 19th century Hungarian physician who discovered that the mortality rate from childbed-fever could be slashed dramatically if doctors would wash their hands with a chlorine solution each time they delivered a baby. The wise doctor's suggestions for maternity care were not taken seriously for at least several decades.

Also relevant is "disconfirmation bias." This refers to the tendency to be critical of new information if it contradicts prior beliefs and, conversely, to accept information without much examination if it is consistent with prior beliefs. In a culture that touts screening early and often, the new guidelines collide with conventional wisdom. We humans also engage in "availability heuristics," the tendency to overvalue dramatic, salient information that comes easily to mind, like personal anecdotes (e.g., "But I know two women who got mammograms who detected breast cancer...").

Our "selective memory" leads us to forget about friends who got mammograms and had false positive scares as well as women who did get mammograms that did not detect their breast cancer. And our tendency to fall for "the emotional reasoning fallacy" causes us to conclude that something is wrong if it provokes emotion (e.g., "the Task Force is insensitive--if it saves just one life, it's worth it," or "these recommendations get me mad.")

Last Friday, the Wall Street Journal reported that "[the Task Force] panel members expressed surprise at the uproar." In retrospect, they should have seen it coming. A hot-off-the press USA Today/Galluppoll showed that 76% "disagree" or "disagree strongly" with the recommendations. Health reform politics is explosive enough. But sprinkle in some cognitive psychology and you have a combustible combination.

Sally Satel, M.D., is a resident scholar at AEI.

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