Letter to the NYT on Mammograms, Pap Smears

The following is a letter I plan to submit to the New York Times.  Since the Times only accepts letters of 150 words or fewer, I’ve added additional points I would have made if given the opportunity below the text of the letter…

I write to voice displeasure with The Times’ coverage of the new recommendations for mammograms and pap smears (“Panel Urges Mammograms at 50, Not 40,” “Guidelines Push Back Age for Cervical Cancer Tests”). These articles lack information readers require to evaluate the new claims and assess their relevance to the larger debate about health care policy.

The Times reports that scientists justify the new recommendations on the basis of a net reduction in health risk. In other words, these scientists say that foregoing the screening procedures will save lives. Yet the only statistical estimates The Times reports are those that reflect the increase in fatality risk due to the missed opportunity of early detection. These figures, which indicate that this risk increase is quite modest, are necessary and relevant not sufficient to evaluate the recommendations. Equally necessary are estimates of the reduced risk of fatality or serious conditions produced by foregoing the procedures. Without these estimates, one cannot tell the degree to which the larger claim — that reducing screenings will improve health – is a matter of conclusive evidence or informed speculation, a distinction that is critical for both patients and policymakers.

I do not know whether the scientists provided such data with their recommendations, but since this information is necessary to understanding the story, it is The Times responsibility to either report it or report its absence.

[Those are my first 230 words, so I need to cut 80.  Here is the rest...]

The implications of this imbalance go beyond the reader’s inability to evaluate the recommendations. In both stories, evidence is provided to support the claim that losses will be minimal but is not provided to support the claim that gains will be obtained. If I trust that this imbalance is the result of the evidence truly available, rather than an omission by The Times, it appears the recommendations are well justified as means to reduce unnecessary treatments but not so well justified as means to improve patient health. This suggests that the recommendations are more motivated by a desire to save scarce resources rather than a desire to improve care quality. In other words, the imbalance suggests that the recommendations are an attempt to encourage health care rationing – precisely the charge made by politicians and others who wish to stir up controversy.

This suggestion is furthered in the pap smear story. The story makes explicit the concern that these recommendations have a political bent:

Arriving on the heels of hotly disputed guidelines calling for less use of mammography, the new recommendations might seem like part of a larger plan to slash cancer screening for women.

but the story refutes this suggestion only with a reference to the motivations behind the timing of the announcement.

But the timing was coincidental, said Dr. Cheryl B. Iglesia, the chairwoman of a panel in the obstetricians’ group that developed the Pap smear guidelines.

The group updates its advice regularly based on new medical information, and Dr. Iglesia said the latest recommendations had been in the works for several years, “long before the Obama health plan came into existence.”She called the timing crazy, uncanny and “an unfortunate perfect storm,” adding, “There’s no political agenda with regard to these recommendations.”

This is a form of damning with faint rhetorical praise.  As my analysis of the evidence provided in the stories demonstrated, the timing of the announcement is only one reason to suspect the recommendations are politically motivated.  A more substantial, and less conspiratorial, reason is that the logic presented for the recommendations implies that cost considerations were taken into account in their formulation.  If this is true, then critics are correct to point out that these findings are based in a science that already includes political concerns and evaluations, namely, the most effective and appropriate ways to spend money.  In other words, this story both suggests and supports a suspicion that these recommendations are politically motivated, even as it ostensibly attempts to refute this suggestion.

My larger point is that these ambiguities and insinuations could be easily avoided with true balanced reporting.  That is, with balanced reporting of the evidence.  If the scientific panels have a set of calculations that show that health outcomes will improve with these recommendations, these should be reported. These figures are both relevant to the evaluation of the claim and serve as a strong argument against the suggestion that the recommendations are politically motivated.  If the panels do not have such calculations, this absence should also be reported.  Without such calculations, it is difficult to see how the claim that overall outcomes can be justified without recourse to an argument about saving resources, and argument which is, whether politically motivated or not, an argument for rationing.