Tuesday, June 21, 2011

Excess of care and the ongoing need for improvements in women's health

One of my main critiques of the HPV vaccine has been that the new technology may pre-empt efforts to improve existing practices. Women's healthcare remains full of unnecessary interventions, insufficient information, and an over-emphasis on reproductive health rather than holistic health. In the case of the HPV vaccine, I have argued that gynecological care remains static and frozen (in some respects) with the availability of new method for preventing HPV, rather than critically refining the way we do things now. And the way we do things now could use some refinements.

Almost two years ago, the guidelines for mammograms, the screening of women's breasts for potential tumors, were changed from recommending screening at age 40 to starting screening at 50. Part of the change was due to concerns of unnecessary tests that may produce false positives. The cost and the stress of the ambiguous results did not seem worthwhile. Further, the earlier testing failed to demonstrate a "significant" reduction of mortality due to breast cancer.

A lot of women were publicly outraged. They felt their health was being sacrificed for solely cost-saving reasons. My favorite post was George Lakoff's, a philosopher who teaches at Berkeley, who claimed that there would be thousands of women's lives affected by the changes. His argument was highly suspect, as he uses arithmetic to argue that nearly 42,000 women would die due to the new regulations. This is a far too simplistic argument for understanding health risks. Further, I expected more from a philosopher; his statement that women would die due to the regulations is completely fallacious. Not every woman with breast cancer dies. The reaction across the States to the change in regulations is a common one when it comes to shifts in existing medical interventions. None of us wants to be the one "sacrificed" for population-level purported benefits. And yet, this sense of entitlement is so very American and so very much part of why we have one of the most bloated and expensive healthcare systems in the world.

In a related article, shortly after the 2009 changes in mammogram recommendations, Barbara Ehrenreich wrote very convincingly about how the breast cancer advocacy industry has, in some ways, co-opted the feminist movement. The pink ribbon consumerism is the new rallying cry for women, rather than more substantive women's health concerns. Women's outrage about the mammogram guidelines' shift lacked a real understanding of the reasoning for the shifts. She also takes Lakoff to task for overly individualizing the experience of breast cancer (by a man, whose wife received a false positive, no less, though she does not make this point). And this undermines women's movements and the quest for improvements in women's healthcare, for which Ehrenreich calls.

Similarly, cervical cancer screening guidelines have also changed in the recent past. Instead of annual screenings with a pap smear (the scraping of cervical cells to identify abnormalities in the cervix), women over 30, who have normal results with a combined HPV test (a DNA-based test that can determine whether a woman has the higher-risk type of HPV that can lead to cervical cancer or the lower-risk type that does not lead to cervical cancer) and pap smear can then shift to the every three years' pap smear. Similarly, younger women should receive the pap every two years. (I should add that the guidelines are very convoluted and full of logic twists and turns that it's no wonder no one knows what is considered "appropriate" anymore.)

There's a recent government study that shows that MDs are actually over-testing women using both the pap smear and the HPV test. The issue of over-testing is similar to the reasons that the mammogram guidelines shifted. Or rather, similar, but also different. Young women are likely to have HPV if they're sexually active. But they're also likely to clear the infection on their own. If all women who are identified as having HPV receive the progressively more invasive interventions due to their positive HPV results, many women will be over-treated than necessary. And here, even more so, I think, than with mammograms, over-treatment is about more than just the economic burden. The biopsies and colposcopies that make up cervical cancer prevention are incredibly traumatic as is the even more invasive technique of loop electrosurgical excision procedure (LEEP).

Both the skepticism about mammograms and excessive gynecological interventions support my argument that we're not actually thinking very carefully about medical technologies. Another recent article on the excessive use of mammograms proposes that mammograms may not be the real reason for the decline in mortality due to breast cancer. The emphasis has been on more is more!! Let's do more! But this thinking obscures the existing problems with well-tread practices, and it fails to improve practices that might require tweaking without full-on replacement of new methods that have their own limitations.

No comments:

Post a Comment