The public debate continues on the controversial breast-cancer legislation that Sen. Amy Klobuchar, D-Minn., is sponsoring in the Senate.
Called the Education and Awareness Requires Learning Young (EARLY) Act, the legislation instructs the Centers for Disease Control and Prevention (CDC) to implement a national education campaign to increase breast-cancer awareness among women between the ages of 15 and 40.
Sounds like legislation nobody could be against, right? But, as I reported twice in June (here and here), many cancer experts and advocacy groups oppose the legislation. Vehemently. They believe the bill will result in unnecessary testing and treatment and do little, if anything, to save lives.
The most visible discussion about the merits (or demerits) of the legislation has been playing itself out on the editorial pages of the Star Tribune and the Los Angeles Times.
Well-intentioned waste of health-care dollars
Just last Friday, the Star Tribune published a letter from Otis Brawley, chief medical officer for the American Cancer Society, that admonished the newspaper for an editorial it had published earlier in the week that favored passage of the EARLY Act. He wrote:
About 5 percent of the 192,000 new cases of breast cancer annually occur in women under 40, and there is no evidence to suggest that a broader education campaign directed at them, as recommended by Klobuchar’s bill, would result in fewer cases or fewer deaths from the disease. … While the legislation is well-intentioned, it could lead to unnecessary treatment and a waste of health care dollars as there is no scientific evidence it will save lives.
And today Christine Norton, president of the Minnesota Breast Cancer Coalition and a breast cancer survivor, added her comments in a letter to the Strib. Young women who receive a breast cancer diagnosis “face difficult choices and have fewer effective treatments than do women in other age groups,” she notes. “But sympathy is not the basis for sound public policy.”
The EARLY Act would devote $45 million to educating young women about “evidence-based methods to lower the risk of breast cancer in young women.” But decades of research have not determined what those methods are. Moreover, there is no evidence that raising awareness in this population would lower mortality. This bill, while well-intentioned, falls short of the mark at every level.
Keeping risk in perspective
An op-ed that ran two weeks ago in the LA Times came to a similar conclusion. Written by Steven Woloshin and Lisa Schwartz, physicians and professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice (and authors of “Know Your Chances: Understanding Health Statistics”), the op-ed makes this startling statistical analogy: A 20-year-old woman has almost the same risk of dying of breast cancer during the next 10 years (1 in 10,000) as a 70-year-old man.
That’s not to say that breast cancer is not a very real worry for women. Of course it is. But it’s important to keep worries about our various risks of disease — risks that change dramatically throughout our lifetime — in perspective.
Law of unintended consequences
And then there’s the troubling question of what exactly — given the known evidence — young women should be told to do to reduce their risk of breast cancer. You might be surprised, as Woloshin and Schwartz point out:
One idea is to have women try to focus on reducing breast cancer risk factors within their control. But as Barnett Kramer, associate director for disease prevention at the National Institutes of Health, has pointed out, the most common risk factor for breast cancer (apart from older age and being a woman) is having children at an older age. In fact, risk starts to rise if a woman has not had her first full-term pregnancy by age 20. There is also some published evidence that, at least among younger women, increased body mass is associated with a lower breast cancer risk. It is hard to believe that the EARLY Act’s sponsors would want to launch a public health campaign encouraging teens to become pregnant or gain weight.
Emphasis should be on family history not ethnicity
One of the groups spearheading efforts to pass the EARLY Act is the United Jewish Communities and the Jewish Federations of North America (which includes the United Jewish Fund and Council of St. Paul). Breast cancer is a particular concern for women of Ashkenazi Jewish heritage — and with good reason. They are at an increased risk of carrying a gene mutation for the disease.
The EARLY Act, as currently written, would encourage more young Ashkenazi Jewish women to receive genetic counseling. But, as Woloshin and Schwartz point out:
[M]edical experts do not routinely suggest genetic testing based solely on race or ethnicity — but rather on family history. If, for example, two or more close family members contracted breast cancer before age 50, that would be a reason to consider testing. The reason behind this recommendation is that the effect of genetic mutations on breast cancer risk — in the absence of a strong family history — is unknown, but the psychological impact of identifying the mutations may be substantial. And there can be physical consequences too. Some women will opt to have their breasts and ovaries removed to reduce risk. Other women may start having mammography or breast MRIs at a very early age. …
Each of these breast-cancer experts believes the EARLY Act’s $45 million allocation could be spent much better elsewhere. Says Norton:
“Let’s get young women at risk of breast cancer the answers they deserve. That requires scientific research into why the mortality rate is higher [for women under age 40], what detection methods would be effective and how best to deal with quality of life issues. A bill supporting that approach would make sense.”