Medicare doesn't pay because there is no evidence you live longer or better as a result

Can journalism aspire to be curious?

On Friday, the New York Times ran this story.

The article begins by explaining that mammograms don’t find all breast tumors — of course they don’t! Even MRI and ultrasound do not. In fact, no imaging modality does. The only way to find all the tumors would be to remove the breast and have a pathologist examine every tiny bit of it. If you did this, you would find lots of tumors you couldn’t see any other way.

But finding a tumor is not the goal of screening. The goal is to find tumors that were going to spread and cause harm, but because you found it early and cut it out and gave adjuvant chemotherapy, it is no longer going to harm you.

It turns out that this is not true for all tumors. Are the extra breast tumors found by MRI or ultrasound the kind that would otherwise kill you? Or are they disproportionately the kind that would otherwise not cause harm in your natural life, or not cause harm till they are detected a year later on mammography and dealt with then (aka no benefit to finding it a year earlier)?

The answer is: no one knows because proponents of MRI and ultrasound, whether in dense or regular breasts, are not conducting the appropriate studies to figure this out. Only large, randomized trials testing whether these additional screenings lower rates of death from breast cancer or distant spread or all cause mortality can answer the question.

Instead, proponents just want to get someone to pay for their hypothesis. They churn out a set of low credibility observational data and lobby Medicare to pay. They find reporters who are unwilling to articulate the opposing view to write about it — enter the New York Times. All this means is that we all pay for something that makes radiologists richer, but might not help women.

In fact, it could be worse. These extra scans might find more lumps and, as a result, women get more surgeries and mastectomies and chemo, but DON’T LIVE LONGER.

Medicare doesn’t pay because there is no data that these scans improve outcomes. Finding tumors does not guarantee you make women better off. If journalism could educate the public about this, we would be a lot better off. Thankfully, there is Sensible Medicine. Consider supporting us by subscribing.