The Backlash Against Screening & Prevention

Put together, a couple stories in the NYTimes today show that while preventive medicine is theoretically the way of the future, it's going to be a cultural challenge getting the public to synch up with the program. First, there's Tara Parker Pope's column about the American Academy of Pediatrics recommendation to prescribe statins to children as a longterm preventive measure against heart disease. The idea is to identify those children at a higher lifetime risk for heart disease as early as possible - as early as eight years old - and take preventive measures to ward off the disease.

The backlash comes from pediatricians, who flag that there is scant evidence that's it's safe to take statins over several years, let alone decades, let alone 40 or 5o years.

The second story kicks in at the opposite end of life: It concerns recommendations for elderly women to undergo multiple mammograms every year to screen for breast cancer. In this case, there's somewhat more sound evidence for the intervention.

The mammography study, published in May in The Journal of Clinical Oncology, looked at the records of more than 12,000 patients aged 80 and older who were given diagnoses of breast cancer from 1996 to 2002. It found that among those who had a mammogram every year or two before their diagnosis, 68 percent found the cancer at an early stage, compared with 33 percent of those who skipped mammograms altogether.

Five years after the breast cancer diagnosis, 75 percent of the frequent screeners were alive, compared with only 48 percent of those who had not been screened for at least five years before their cancer was found.

So what's the controversy? Basically, it boils down to the idea that by the time women hit 85 or 90, there are fairly low odds that they'll die of breast cancer. Basically, they're so old that they're more likely to die of something else, not breast cancer.

In both cases, the issue seems to pivot on one question: What constitutes sufficient evidence to recommend screening for large populations? Is one study enough? And when you're talking the very old or the very young, screening measures risk bumping up against a 'yuck factor' - the idea that we are medicalizing populations, or forcing people into medical interventions, when they should "just be living."

My sense is that these are simply the first bumps along a pretty clear path towards a whole arsenal of screening panels. In a year or two, pretty much every demographic - be it the very young, the very old, or some slice in between - will have a handful of screening tests that they fall under. The sense of outrage that comes with these recommendations will fall away, because it'll be up to us, as individuals, to decide whether or not to plug into these panels. But better to have the option of engaging early, and face our risks, rather than wait for the worst to happen.