Scans, Stresses, and Sacred Cows

     
 The first time I heard that we might seriously be entertaining healthcare reform in America, during the Clinton administrations, I had an instinctive flash of apprehension:  Our huge Boomer population was going to require triaged healthcare by the time the first wave of us reached Medicare eligibility.  Unavoidably.  And, I knew, if we were ever to broaden service availability to more Americans, some form of care rationing would have to happen sooner, rather than later. I sometimes fail to understand how anyone could be surprised by this, much less bother to be incensed.  Other times, I get it...like, when you ask me if I want my daughter to have ready access to a mammogram each year after her fortieth birthday.
  
 I also knew that our national sense of entitlement to state-of-the-art healthcare isn't really national at all; it's class-based.  Our system, with its proprietary hospitals, televised pharmaceutical ads, doctors who build their own labs, and care paid by the procedure, generates the expectation that each of us will get every available treatment when we need it.  Some of our most popular television shows  have taught us to expect George Clooney and heroic measures for every single patient.  We're spoiled, right?  Not all of us.  Even the belief in a national sense of medical entitlement is a prerogative of the middle and upper classes.  The chronically uninsured and under-insured were never confused on this score. They already knew they couldn't afford to get sick.  Now, we might be approaching classless medical care.  It's meant to be more fair, and many of us will benefit, but many of us will have to shed our illusions.  


 My third insight (I was channeling Rasputin that day) was that our generation should accept necessary rationing with something like grace and courage.  Gerontological psychology posits that, at some late stage along the way, the mentally healthy elders really do become altruistic toward the generations that follow.  Something properly shifts in the cognitively intact septuagenarian and octogenarian; they know it's time to get off the stage without trashing the set.  When I studied this subject in the '90's I was a couple of decades off from realizing that altruism, but I could imagine feeling it.  I hoped I would feel it.  The alternative was shameful, even for a card-carrying member of the Me Generation.  I didn't expect to have to summon real epochal altruism so soon, but here it is...and I'm damned if it isn't all about boobs, again.

 The news this week on the U.S. Preventative Services Task Force's mammogram recommendations is forcing us to think about evidence-based medicine in theory, as we must if we want to call ourselves good voting granddaughters of the suffragettes, and forcing us to accept that this really does mean you, me, and our daughters. Women are facing the unattractive notion that, when it comes to breast cancer, we're the sacred cows at the center of the healthcare battle.  This is the issue we probably never expected to face first. Given the ubiquitous pink ribbon and the convincing stats from the nineties that clearly showed improved breast cancer survival rates with early, annual screens, who could have guessed we'd have to be rethinking mammograms?


 But the evidence for annual screenings before age fifty is, apparently, not so clear-cut, after all.  In fact, it gets really scary for the females at highest risk.  Tiffany O'Callaghan, Time Magazine staff blogger, reports,

  In the review of six studies that included roughly 5,000 high-risk women, who have an increased likelihood of developing breast cancer due to genetic reasons or family history, for example, researchers found that high-risk patients who were exposed to radiation were 1.5 times more likely to develop cancer than high-risk patients who had no exposure. High-risk patients who had greater levels of exposure to radiation—either beginning mammograms before age 20, or having five or more exposures—were 2.5 times more likely to develop cancer.

 While you and I may have been congratulating ourselves on doing the very best we could for our health by getting those annual scans, doctors have always known that radiation mammography carries its own risks. Oh, yeah, I knew that. And alternative screening methods like MRI are either not safer or are more likely to produce false positives. According to the research cited by the Task Force, some tumors are slow-growing and some are aggressive, but, once detected , standard medical policy is to treat all tumors aggressively with surgery, chemo, radiation, and hormone therapy. In Time Magazine's December 7th article, "The Mammogram Melee", I find:

It's impossible to say how frequently such "overdiagnosis" occurs, according to the task force, but the data did conclusively show that in order to save the life of one woman in her 40s from breast cancer, 1,904 women would have to be screened every year for up to 20 years. Because it judged that the risks of harm from annual screening outweighed the benefits, the panel issued its controversial recommendation that most women ages 40 to 49 need not get routine mammograms.

  Are you finding this stressful, too?  I couldn't help thinking about the women I knew whose scans had shown positive...about which ones could have afforded to postpone the tests, about what their lives were like before and after their scans.  I got nervous enough to do some slightly tangential research, looking to the National Cancer Institute's information on the relationship between stress and cancer incidence, spread, and treatment outcomes.  They're pretty careful folks, so they equivocated a bit, saying, "More recent research with animal models (animals with a disease that is similar to or the same as a disease in humans) suggests that the body’s neuroendocrine response (release of hormones into the blood in response to stimulation of the nervous system) can directly alter important processes in cells that help protect against the formation of cancer, such as DNA repair and the regulation of cell growth (6). 

    
 Instinct is the short form of recall, and it came in handy again today.  I remembered that I'd run across some studies on stress, social isolation, and cancer while reading John Cacciopo's Science of Loneliness webpage.  I went searching and found this on an article by Suzanne Conzen:

A socially isolated, stressful environment can speed up the growth of breast cancer, researchers studying the effects of stress in animal models reported Tuesday.

Social isolation can actually change the expression of genes important in the growth of mammary gland tumors, according to Dr. Suzanne D. Conzen, an associate professor of medicine at the University of Chicago and the study's lead author.

"As far as we know, this is the first assessment of gene expression in mammary glands, looking at the molecular basis for differences in tumor development under the setting of social stress," Conzen said at a news conference Tuesday.

That's a teaser.  Here's the original article.  Go get it, girl .


I'm not building a careful argument in this post.  This is about how rationality breaks down when it gets personal in the healthcare debate.  I liked it better when we were debating about somebody else's healthcare, frankly.  Breast cancer, on the other hand, is very personal:  it's my aunt, my mother, my grandmother.  It could be my cousin, it could be my best friend, it could be me.  You've heard of the NIMBY (not in my back yard) argument as it applies to congressional bills; this is the NUMS (not under my shirt) argument, and it doesn't sound any smarter when it comes out of my mouth, rather than Nancy Grace's.  


Okay, so, there's a failure of internal logic to the post and the author's gone girly.  I've done my research; then, in typical female fashion, I'll follow my gut on this one. To break it down, let me tell you like I'd tell my best friend's daughter:  Honey, if you turn forty and your marriage stinks, or your job makes you cry several times a week, or you're sandwiched between ailing parents and unbearable teenagers, or you're living alone and hating it, push for that mammogram...that year and every year until things get better.  And get it off your chest; I'll listen.