[Congressional Record Volume 140, Number 45 (Thursday, April 21, 1994)]
[Extensions of Remarks]
[Page E]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: April 21, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
          MAMMOGRAMS: MIXED MESSAGES ON A LIFE AND DEATH ISSUE

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                        HON. PATRICIA SCHROEDER

                              of colorado

                    in the house of representatives

                        Thursday, April 21, 1994

  Mrs. SCHROEDER. Mr. Speaker, I draw my colleagues' attention to a 
column in the April 11, 1994, New Republic magazine about the mixed 
messages going out to women on when to get mammograms.
  The author, Michael Kinsley, makes a number of good points, among 
them that the National Cancer Institute's recent about-face on the age 
at which women should get annual screenings has placed an unfair burden 
on women to make choices the experts can't make.
  Kinsley also points out that such Government recommendations are 
crucial when it comes to insurance coverage.
  The Congressional Caucus for Women's Issues has said that screening 
mammograms should be covered every 2 years for women 40 to 49, with 
applicable cost-sharing on a sliding scale; and every one to two years 
for women 50 and older, with no cost-sharing. Additional screening 
mammograms should be free for any women at high risk. And annual 
clinical breast exams should be covered for women over 40.
  It is the caucus's position that until there is a clear consensus on 
this issue, it is better to err on the side of caution. Key to 
developing that consensus will be better research, and women will be 
watching for that.
  I remind my colleagues that breast cancer is expected to kill 46,000 
American women this year and afflict another 182,000, and I submit the 
Kinsley article for inclusion in the Congressional Record.

                 [From The New Republic Apr. 11, 1994]

                          TRB From Washington

                          (By Michael Kinsley)

       In December the National cancer Institute revised its 
     guidelines on mammogram screening for breast cancer. 
     Previously, the NCI had recommended mammograms every year or 
     two for all women over the age of 40. Now it recommends 
     annual mammograms for women over the age of 50. As for those 
     between 40 and 50, the institute's position is that the 
     evidence is not clear one way or the other. Women, it says, 
     should study the data and decide for themselves.
       This is a deeply unsatisfying recommendation, for two 
     reasons. First, if the full-time experts at the National 
     Cancer Institute can't decide whether mammograms are 
     worthwhile for women in their 40s, how on earth is a 
     nonexpert with other demands on her time supposed to make a 
     sensible decision for herself?
       Second, this is not a question that society can leave 
     completely up to individual women. In various circumstances, 
     a decision must be made at the level of social policy. Health 
     care reform is the most obvious example. If we are going to 
     guarantee something called ``health care'' to everyone--one 
     way or another--does that or does it not include mammograms 
     for women in their 40s? But the question arises apart from 
     health care reform. Even under current arrangements, 
     insurance companies must decide whether this is a benefit 
     they will pay for, and the government must decide whether to 
     cover it in Medicaid, the military health system, etc.
       So what's the answer?
       It seems obvious, to start, that there is no magical 
     dividing line at age 50. The experts are unanimous that 
     regular mammograms starting at 50 cut the breast cancer death 
     rates by one-third. But if mammograms are tremendously 
     valuable at age 50, they can't be worthless at age 49. And if 
     they are at least somewhat valuable at 49, they are 
     only slightly less valuable at 48, and so on. Clearly it's 
     a continuum: the exam gets more useful as you get older. 
     Anywhere you draw the line is going to be arbitrary.
       It seems implausible, therefore, that regular mammograms at 
     ages under 50 can be completely without purpose. After all, 
     mammograms of women in their 40s do catch cancer in about one 
     out of 400 cases, and it has to be better to catch such cases 
     earlier rather than later. One doctor quoted in The New York 
     Times said that women should be warned of the ``drawbacks'' 
     of mammograms in their 40s. To be sure. But the drawbacks 
     seem pretty farfetched. The test itself is harmless. There is 
     the psychological trauma of ``false positives''--initial 
     diagnoses of cancer that turn out to be wrong. And apparently 
     scar tissue from the biopsy of lesions that prove benign can 
     sometimes block the view of genuine cancerous lesions in 
     later years. Still, if that was the entire downside, it would 
     be hard to see the problem with making mammograms standard 
     for women in their 40s.
       Of course there's the cost. The NCI insists that economic 
     considerations did not figure in its guideline change. But 
     they inevitably figure in real life. If all 18 million 
     American women in their 40s got an annual mammogram, at $150 
     a pop, that would cost $2.7 billion per year. The Cancer 
     Institute maintains there is no good evidence that any lives 
     would be saved as a result. But future studies may change 
     that conclusion. As a very rough back-of-the-envelope 
     calculation, take the one in every 400 that identify a 
     cancer, and figure that (say) half of those might otherwise 
     have gone undiagnosed until it was too late. It works out to 
     more than $100,000 per life saved.
       Worth it? You can argue that one either way. But the larger 
     point doesn't go away in any event. What about women in their 
     30s? Their 20s? Their teens? What about prostate exams for 
     younger and younger men? These exams will be ever more 
     expensive per life saved, yet they are unlikely to prove 
     completely worthless. But you've got to draw the line 
     somewhere, and at the point where you draw that line you are 
     putting a price tag on human life--even your own life in some 
     cases.
       Americans are notoriously bad at questions like this. We 
     find it hard to make rational judgments about very small 
     risks of very bad outcomes (like the risk of dying of breast 
     cancer due to forgoing a mammogram in your 40s). Usually, 
     political conservatives are the more hardheaded bunch. They 
     enjoy ridiculing--often accurately--liberal hysteria on 
     matters ranging from environmental hazards to auto safety to 
     nuclear deterrence. On this question of mammograms, however, 
     they have seen an opportunity to score points off of 
     President Clinton by pandering to exactly the sort of 
     anxieties they usually mock.
       The standard benefits package under the Clinton health care 
     reform plan offers mammograms beginning only at age 50. ``As 
     if by imperial edict,'' charges Bernadine Healy, the Clinton 
     plan ``has ruled out screening mammography for women in their 
     40s.'' She accuses Clinton of using the NCI revised 
     guidelines ``to justify a cost-based decision to limit 
     women's health care choices.'' Healy was director of the 
     National Institutes of Health until 1993. The National Cancer 
     Institute is part of NIH. Thus the guidelines revisions she 
     objects to were formulated largely on her own watch. But now 
     she is a Republican Senate candidate from Ohio, and so she 
     has happily taken up this theme, shared by other 
     ``conservative'' critics of the Clinton plan.
       In truth, the Clinton plan ``rules out'' nothing. It 
     defines a minimum benefits level, which any plan purporting 
     to assure health care for everyone must do. Women in their 
     40s who could afford them would be perfectly free to have 
     mammograms, and insurance companies would be perfectly free 
     to offer mammogram coverage. (Free market conservatives, 
     though, should realize that there is little point in 
     ``insuring''against a certain event--like an annual 
     mammogram. The extra cost of the insurance will have to equal 
     the cost of the mammogram itself--plus insurance company 
     overhead.) And don't forget that Clinton's plan would make 
     mammograms available for the first time to millions of women 
     in their 50s, for whom the value is unquestionable.
       But the telling phrase is ``cost-based.'' Is it now the 
     ``conservative'' position that any ``cost-based'' health care 
     decision is immoral? That any consideration of the ratio of 
     cost to benefit amounts to health care rationing? If so, 
     ``hold onto your wallet,'' as those guys used to like to say.

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