There has been plenty of information disseminated more recently about why mammograms can potentially cause more harm than good. So for healthcare professionals, where should they draw the line on recommending this kind of screening for women? And are financial incentives from providers troubling?
A new JAMA article released today highlighted this dilemma.
Breast cancer screening is a case in point: incentives for completion of mammograms are an ethically disconcerting distraction in a complex decision-making process. However, incentives for making an evidence-based active choice about breast screening can be ethical—even if this policy may avert fewer breast cancer deaths overall.
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There are many challenges with deciding whether or not mammograms are ideal, and the article spelled out why.
First, not all screened women benefit—screening reduces chances of dying of breast cancer, but some screened women still die of it. Second, a proportion of cancers identified in screening never develop into lethal tumors. Such overdiagnosis commonly leads to overtreatment since partial or full surgical breast removal and hormone therapy, radio therapy, or chemotherapy are typically initiated after any confirmed findings. Third, all participants risk periods of worry due to false positives and biopsy complications.
One thing is clear: Women should be fully informed about how to manage their health and be aware of breast cancer signs or concerns – especially those above 50.
There seems to be somewhat of a fine, blurry line when it comes to this procedure currently, though. The goal is to keep women informed and in control of their health without the unnecessary risks. But age and income-level also play significant roles in these decisions and the desire women might have to respond to financial incentives to get screened.
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Even with current evidence-based decision aids that are not used universally, only 24%to 50% make informed choices. Less-educated lower-income groups face greater challenges because incentives, especially larger financial ones, have more salience for them and may unhelpfully shortcut informed decision making. Increased overall screening rates resulting from incentivized uptake among low income women who would not have opted for screening absent the incentive are ethically troubling. In addition to insufficient respect for their autonomy, the disproportionately higher economic and psychological burden associated with possible harms from screening must be especially concerning.
When it comes down to it, each case is different for individuals. But the JAMA article emphasized one key point:
A focus on completion rates alone is ethically misguided given that the balancing of potential benefits and harms is highly preference sensitive. Mammogram choices should be made by meaningfully informed women—not their physicians, health plans, policy makers, or other parties.
Photo: Flickr user Aine
