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Tuesday, November 3, 2009

unthinkable thoughts about preventive medicine

Of course it’s true that preventing disease is less painful and less costly than treating disease. Or is it?

Take the recent New York Times article (http://www.nytimes.com/2009/10/21/health/21cancer.html) addressing mammogram and prostate cancer screening. Apparently over the last 20+ years of screening with mammograms, we have been able to discover many more breast cancers that are small, and might never have been noticed, and probably never would have progressed to the point of hurting anybody. This has given rise to alarming statistics, such as the one that breast cancer incidence has risen 40%.

We have long known that detecting prostate cancer early, especially in older men, finds many cancers that would never have caused any injury and would never have been noticed had we not screened the men. When we find cancer, we usually remove it, and for women with breast cancer this means amputation of a breast or radiation therapy, and often chemotherapy. For men with prostate cancer this means surgery on their very delicate private parts after which they often have trouble with bladder or sexual function.

But even if mammogram screening did detect cancer early, thus protecting women from getting more serious breast cancer, which honestly it sometimes does, is it really less painful and less costly than treating the disease? Mammogram screening, it is estimated, costs about $105,000 per year of life saved if we screen women yearly starting at age 40. Because mammograms are somewhat difficult to interpret, many of those women have breast cancer scares, and all of those women get their breasts painfully smashed flat once a year. Encouraging them to get those mammograms is the job of doctors and nurses who might use that energy to provide other more life affirming activities. The focus on the breast as the seat of cancer, rather than of, say, love or courage, puts women in the position of being at war with their bodies.

Let’s go back to the $105,000 per year of life saved. I certainly love my women friends and relatives enough to believe that a year of their life would be worth $105,000, but isn’t it possible that if we spent that money on something a little different than mammograms, we might be able to buy more than a year of life? I could support a family, for instance, for a year on $105,000.

I do know and love people who have had screening mammograms, found breast cancer, had it cured, and are now healthy. I think some of them might have died had they not had a mammogram. I am not ready to say that women shouldn’t get screening mammograms. It is, however, not necessarily accurate that preventing disease is less costly and less painful than treating it, at least in the case of breast and prostate cancer.

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