Lessons from the Mammography Wars

Controversy erupted when the Preventive Services Task Force recommended mammograms biannually for women over age 50 instead of annually for women over age 40. The controversy demonstrated that the health care industry needs to recognize gray areas in treatment and work to keep vested interests from dictating guidelines for care.

Although the benefits of treatment must be determined for each patient, general guidelines are necessary to help physicians make treatment decisions. Efforts to systematize medical care have tended to lower the threshold for treatment and, therefore, to extend treatment to more people; when this happens, the profession providing the service becomes more valued and profitable.

The authors recommend two thresholds for treatment: one above which the benefit of treatment outweighs the risk of harm, and one below which the risk of harm outweighs the benefit of treatment. The area in between requires individualized judgments. The authors also recommend treating the health care industry like other industries and instituting controls to reduce the impact of industry self-interest. This would involve separating the process of medical evidence review from guideline formation, ideally with a system of independent panels to review medical evidence and adjust care guidelines accordingly.