There’s no way this complex issue can be covered in one post, but thankfully there have been some really thoughtful pieces written by others that we can pull from. For example, my own comments led to this headline on the AtlanticWire: Politics Beats Science in Cancer Screening Debate, featuring a terrific piece by Kevin Sack in the NY Times (Screening Debate Reveals Culture Clash in Medicine), comments by Ezra Klein (WaPo), Arthur Caplan (MSNBC), and David Dayen (Firedoglake). The author of the AtlanticWire piece jumps to the heart of the issue and writes:

According to the panel, the timing of the new pap smear guidelines is entirely coincidental. But politicians — already taking steps to distance themselves from the obviously unpopular mammography guidelines — seemed wary Friday. The anger from women, doctors, and advocacy groups over the relaxed screening guidelines is revealing, pundits say. They argue that it reveals a divide between the hard science of cancer screening and the explosive, personal politics of health.

Kevin Sack’s piece adds something to the debate in the form of a graphic showing that mammogram utilization has fallen recently in other age groups, and that a steady bit more than 60% of women 40-49 get yearly mammograms (for those interested, a state by state table is here.)

Presumably for the 40% that don’t get yearly mammograms, this represents no change. But the recommendations have been presented to younger women as if something important is being taken away from them, rather than what the panel actually said: that the experts suggest that they cannot determine whether yearly mammograms in that age group for low risk women are helpful or harmful and that the best thing to do is discuss it with your own doctor.

The balance of benefits and potential harms, therefore, grows more favorable as women age. The precise age at which the potential benefits of mammography justify the possible harms is a subjective choice. The USPSTF did not find sufficient evidence to specify the optimal screening interval for women aged 40-49.

That, of course, assumes you have a doctor, and that’s where the interface between health reform and this topic is most obvious.

As to what the risk is from breast cancer, and why the recommendations were changed away from “just do them”, this St. Louis Post-Dispatch piece notes:

The British Medical Journal published an article to help people understand the risk in simple terms.

It means that if 1,000 women don’t get mammograms, we can expect four of them to end up dying of breast cancer. If all 1,000 women do get regular mammograms, three will still die of breast cancer.

No matter the odds, many doctors and patients say any life saved is worth everyone getting the mammograms.

“We’re all in agreement that this is not the best tool, but does that mean we should take the next step and not screen at all?” said Dr. Burton Needles, medical director of the cancer center at St. John’s Mercy Medical Center in St. Louis. “Most of us who treat patients with cancer feel that the benefits still outweigh the risks of screening.”

For more details, Kossack charliehall (biostatistician) wrote this more detailed diary on studies available through the Cochrane database, and noted the same result as above: women in the screening group were just as likely to die as women in the no-screening group.

Given that kind of information, the panel suggested individualized care over rote screening for everyone. And on the topic of relying on routine breast self-exam, which was another recommendation from the panel, Orac (pseudonym of a practicing surgeon from ScienceBlog’s Respectful Insolence) notes:

The USPSTF’s recommendation not to teach breast self-examination (BSE) is another point of controversy. Despite a lot of enthusiasm for the practice, Cochrane Reviews and other evidence have failed to find convincing evidence that routine regular BSE saves lives. I wish it were otherwise, but it appears not to be, even though there are compelling anecdotes out there of women who did find a lump on BSE and it turned out to be cancer. Unfortunately, overall, the evidence to support BSE is weak. On the other hand, even the Cochrane Collaboration, which I have in the past sometimes accused of methodolatry and “nihilism” with respect to screening concluded:

Some women will continue with breast self-examination or will wish to be taught the technique. We suggest that the lack of supporting evidence from the two major studies should be discussed with these women to enable them to make an informed decision. Women should, however, be aware of any breast changes. It is possible that increased breast awareness may have contributed to the decrease in mortality from breast cancer that has been noted in some countries. Women should, therefore, be encouraged to seek medical advice if they detect any change in their breasts that may be breast cancer.

Indeed, on a purely practical level, I see nothing wrong with women being taught to be aware of how their breasts normally feel and to bring to a physician’s attention any changes that concern them and still encourage that, but there really is no good evidence to support BSE.

To add to that, Our Bodies Ourselves (Boston Women’s Health Book Collective) wrote that the case against screening is not new:

New government guidelines recommending that women start screening for breast cancer at age 50 instead of 40 set off a round of criticism this week and caused much confusion for women who for years have been told that early detection saves lives.

But a number of women’s health organizations, including Our Bodies Ourselves, the National Women’s Health Network and Breast Cancer Action, for years have warned that regular mammograms do not necessarily decrease a women’s risk of death. Premenopausal women in particular are urged to consider the risks and benefits.

In fact, the NWHN issued a position paper in 1993 recommending against screening mammography for pre-menopausal women. It was a very controversial position at the time — even more so than now. The breast cancer advocacy movement was in its infancy and efforts were focused on getting Medicare and insurance companies to cover mammograms. What the NWHN found — and other groups have since concurred — is that the potential harm from screening can outweigh the benefits for premenopausal women.

The above statement is important for several reasons. This is not a male view of the world superimposed on women. It’s also not a view suddenly brought into the discussion by those wanting to focus on cost and cost alone. it predates this health bill, and it predates cost control discussions in the House and Senate, and in the Obama administration. More from Our Bodies Ourselves:

I don’t believe the new guidelines are politically motivated, nor are they “patronizing” to women simply because they call into question the stress related to biopsies and false positive results. Rather, the guidelines provide a useful framework for helping each of us to decide when is the best time to begin screenings and the intervals at which they should be repeated.

Personal health remains just that: personal. Note what the World Health Organization has to add on BSE:  

There is no evidence on the effect of screening through breast self-examination (BSE). However, the practice of BSE has been seen to empower women, taking responsibility for their own health. Therefore, BSE is recommend for raising awareness among women at risk rather than as a screening method.

++++++

So what do you do when you feel you are sitting on data that contradicts the status quo? How do you convey that information to the public? It’s not like there’s nothing written on the topic. Recognizing the political and social impact of the guidelines is a must, and failure to do so is a mistake, one that science and government types seem to make a lot. These particular guidelines won’t be implemented immediately in any case. Physicians and the public still need to read and accept them. The likelihood of any such thing happening, or participatory and reasoned dialog occurring with the public with the current political atmosphere, is nil (now, those are odds we can all understand.) But if the recommendations make sense, further supporting data will present itself and the discussion will go on.

Note that none of the above has anything to do with insurance companies. That’s a side issue, more likely to be settled in the health reform debate than with these recommendations. But if Republicans want to make an issue of this (and they will), they are going to have to make an issue of evidence-based medicine.

Evidence-based medicine (EBM) aims to apply the best available evidence gained from the scientific method to medical decision making. It seeks to assess the quality of evidence of the risks and benefits of treatments (including lack of treatment).

EBM recognizes that many aspects of medical care depend on individual factors such as quality- and value-of-life judgments, which are only partially subject to scientific methods. EBM, however, seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure the best prediction of outcomes in medical treatment, even as debate continues about which outcomes are desirable.

Our own Christopher Hughes recently wrote a diary on evidence-based vs anecdotal medicine.

“Experience,” or anecdote, is sometimes helpful in medicine, but often harmful, because we physicians often internalize our experience into hard rules about treating patients. This often leads us down dangerous paths.

Evidence based medicine is long overdue counterweight to this kind of medical practice. EBM, when evidence is available, makes us think hard about our practices: Are we doing this because that’s the way we’ve always done it, or because we have scientific research to back up our decisions?

That is the future of medicine. These guidelines will stand or fall on their merit, but given the fact that the US is 19th of 19 in preventable deaths, the way we do things is going to have to change. And that may mean recognizing when cancer screening is helpful and useful (colonoscopy) and when it’s not (Pap smears before age 21.) And it may also mean allowing ourselves to debate the issue without accusing each other of trying to kill women. Personally speaking, I really haven’t tried to kill any women all this week, and I don’t intend to start this weekend. But if we don’t discuss this, we won’t make any progress on preventable deaths. And that, my friends, is progress that has to happen.

For the meantime, I am sorely tempted to suggest that if you want people to get mammograms, tell them they can’t, and if you want to get people not to get flu shots, tell them they have to.

Sunday punditry. Read it early, talk about it late.

Frank Rich on Sarah Palin:

But no matter how much Palin tries to pass for “center-right,” she’s unlikely to fool that vast pool of voters left, right and center who have already written her off as unqualified for the White House. The G.O.P. establishment knows this, and is frightened. The demographic that Palin attracts is in decline; there’s no way the math of her fan base adds up to an Electoral College victory.

Yet among Republicans she still ties Mitt Romney in the latest USA Today/Gallup survey, with 65 percent giving her serious presidential consideration, just behind the 71 for her evangelical rival, Mike Huckabee.

Maureen Dowd:

Yet Democrats would be foolish to write off her visceral power.

As Judith Doctor, a 69-year-old spiritual therapist, told The Washington Post’s Jason Horowitz at Palin’s book signing in Grand Rapids, Mich., “She’s alive inside, and that radiates energy, and people who are not psychologically alive inside are fascinated by that.”

No one should confuse winning the GOP nomination (which she can do) with winning the election (when 60% think you are not qualified, you can’t.) Maureen goes to to say Obama’s too intellectual, blah, blah, blah.

Ron Brownstein via Ezra:

“I’m sort of a known skeptic on this stuff,” [MIT health economist Jonathan] Gruber told me. “My summary is it’s really hard to figure out how to bend the cost curve, but I can’t think of a thing to try that they didn’t try. They really make the best effort anyone has ever made. Everything is in here….I can’t think of anything I’d do that they are not doing in the bill. You couldn’t have done better than they are doing.”

Gruber may be especially effusive. But the Senate blueprint, which faces its first votes tonight, also is winning praise from other leading health reformers like Mark McClellan, the former director of the Center for Medicare and Medicaid Services under George W. Bush and Len Nichols, health policy director at the centrist New America Foundation. “The bottom line,” Nichols says, “is the legislation is sending a signal that business as usual [in the medical system] is going to end.”

More of same from Center on Budget and Policy Priorities:

The health reform bill that Senate leaders unveiled yesterday meets two rigorous fiscal tests: it reduces deficits over the next decade and beyond, and it puts long-term downward pressure on health care costs.

There are, however, still issues with affordability:

The health reform bill that Senate leaders unveiled on November 18 makes health coverage more affordable for millions of households of modest means, as compared to the bill that the Senate Finance Committee approved last month. The amounts that many families and individuals would pay for coverage would be less than under the Finance Committee proposal.

For people between 134 percent and 154 percent of the poverty line, however — people with incomes around $25,000 to $28,000 for a family of three — premiums would actually be higher than the already significant amounts they would have to pay under the Finance Committee bill. Modifications are needed at some point as the legislation moves forward to ensure that near-poor families and individuals do not face insurance premiums and cost-sharing charges that many of them could have difficulty affording.

David Broder does his own rigorous analysis, Beltway style: he asks “every expert” that agrees with him what they think of the new health care bill and ignores the CBO and the ones that don’t.

Via Jay Rosen on twitter, this:

The job cuts at the Washington Post on Friday have produced a round of comments, broadly summed up by Steve Yelvington earlier today. They certainly begged the question that occurred to me as a former employee of both the Post and WPNI, its soon-to-be merged online operation: “What explains this kind of decision?”

They’ve decided the dead tree paper is more important than the web site.

CIDRAP:

Health officials in Wales today announced the identification of a cluster of patients in a Cardiff hospital who are infected with oseltamivir-resistant pandemic H1N1 influenza.

Also today, Duke University Medical Center in Durham, N.C., reported that oseltamivir-resistant H1N1 viruses were found in four very sick patients hospitalized there over the past 6 weeks. A Duke press release said all four patients had been in the same hospital unit, but it did not specify how many were there at the same time.

This is what we dread. Small numbers, but keep an eye on this.

Like a gift from God, Sarah Palin’s Rogue-A-Palooza tour (w/special guest) descended on America this week.

Over the next few months, hundreds of millions of Palin’s Facebook friends will visit book stores – many for the first time – to meet their idol face to face.

And a sexy time will be had by all.

Meanwhile, the Jews will be flocking to Israel.

Tonight’s Diary Rescue was brought to by the fine work of the following Rescue Rangers: shayera, jlms qkw, Yat Pundit, grog, sunspark says, and dadanation who also mimicked being the editor.

The Diaries, Rescued

• Librarian Dem tells the story of an encounter with some patrons in Library users against health care bill. (shayera)
• KibbutzAmiad shares a personal story in Just another murder-by-spreadsheet death. (shayera)
• change the Be shares what I’m thinkin right now, and it’s positive thoughts about Levi Johnston. (jlms qkw)
• CornSyrupAwareness highlights the hypocrisy of the right when it comes to spending priorities in For the GOP Stimulus Spending In Iraq is A-OK (Picture Diary). (grog)
• DParker looks at two cases pending before the Supreme Court and answers the question How does the criminal justice system create injustice? (grog)
• teacherken offers an interesting Advent reflection in 21 November 1943 Dietrich Bonhoeffer. (YatPundit)
• bob zimway discusses Multiple Personality Disorder in Treating A Dissociative Disorder with Marijuana. (YatPundit)
• Minerva isn’t talking about Superman when reminding us why relying on private insurance companies to do the right thing all by themselves is a very bad idea in There, up in the sky – its a bird… its a plane… (dadanation)

The Extras, Usual

jotter brings us High Impact Diaries: November 20, 2009.

carolita has tonight’s Top Comments 11-21-09 – Enlightened Edition.

The Paragraph, Closing

Please use this as an Open Thread as well as your chance to promote your favorite diaries of the day. Respectful engagement is most welcome here. Please keep in mind that each Diary Rescue’s daily purview extends from 3pm PST yesterday to 3pm PST today. Shamelessly self-promote or pimp for a friend in this Open Thread!

The South Carolina House Judiciary Committee is convening next week to hear arguments on whether whether Gov. Mark Sanford needs to take a permanent hike from the Governor’s office:

State lawmakers have considered impeachment for months, but this announcement is the first formal consideration of such a move. It came two days after the State Ethics Commission said it had found probable cause to hear ethics complaints against Mr. Sanford, also a Republican.

The commission, whose nine members were appointed by the governor, did not say what charges it would pursue, but it reviewed several accusations against Mr. Sanford: that he had used state airplanes for personal or political reasons, bought high-priced plane tickets in violation of policy, failed to disclose trips on private planes and misspent campaign contributions.

…

Mr. Harrison has appointed a committee of four Republicans and three Democrats to meet next Tuesday. A majority vote of the full 25-member Judiciary Committee would be required to bring the matter up for a House vote when it convenes in January. If the House votes to impeach, Mr. Sanford would be suspended from duty immediately.

The Senate would then conduct an impeachment hearing. It is not clear what would happen if the Senate failed to take up the impeachment resolution, but it is possible the governor could remain suspended indefinitely as state business proceeds.

Couldn’t happen to a nicer guy.

This is what counts as a liberal these days?

Steve Benen pretty much nailed it with these observations:

Obama isn’t “leading with his chin”; he’s tackling the issues in front of him. That’s what presidents do. Obama bowed to the Japanese emperor as a matter of protocol, and no one cares except the media establishment. Obama isn’t “dithering” — though it’s good to know Chris Matthews is willing to read directly from Dick Cheney’s script — he’s crafting a forward-thinking U.S. policy, which is what Bush/Cheney should have done a long time ago.

Purely from a business point of view, doesn’t MSNBC realize that between this sort of nonsense and Glenn Beck, it shouldn’t be a mystery why ratings for The Ed Show are regularly beating Hardball’s live broadcast.

cab drollery: For those naive enough to be laboring under the delusion that the Obama administration’s Department of Justice is any different than the Bush administration’s, allow me to disabuse you of that misconception.

The Big Picture: How overrated is sentiment in economics?

alicublog: The Children of Zhdanov

Corrente: What we can learn from Iceland

Mondoweiss: Feeling the hate in Washington

The Grey Matter: Light bulb moment, striking statistic, dramatic change

Cartoon via. h/t The Political Carnival.

Open thread below…

A little bit of ephemera from an early sixties documentary, we join, in progress, a bit of a work session in Gerry Mulligan’s apartment. Tom Jobim is playing his One Note Samba when Mulligan joins in on clarinet. They jam for a bit, but Gerry isn’t happy with a note or two that he blows, so they stop, discuss, and swing the song out perfectly.

I’m no trained musician, and I’m still not quite sure what exactly they were discussing, but I love watching great artists in the process of working a piece through.

DOWNLOADS: 446

PLAYS: 203

(“Give Me Your Tired, Your Poor, Your . . . .never mind”)

Since debate on the issue of our current Immigration laws should be heating up soon, this may be jumping the gun. But it’s never too early to start getting some historic perspective on issues. So this post is about the debate over the McCarran/Walter Immigration Bill of 1952.

The program, American Forum Of The Air, hosted a debate on the bill with Senator Herbert Lehman (D-New York) and Congressman J. Frank Wilson (D-Texas)on May 17, 1953.

Sen. Herbert Lehman: “Aliens already in this country can be apprehended and placed in custody. In some cases they can be deported without even the benefit of a hearing. Mister Blair, the McCarran -Walter Act took over all the worst features of all the immigration laws which have been enacted over the last thirty or forty years. But it added many new provisions that were equally bad and combined the whole structure into a legal code which is anti-humanitarian, anti-foreign and, in the profoundest meaning of the word Un-American. It is a complex law and very difficult to summarize in all of its details. But if we are to keep faith with our American traditions, this law, in my opinion must be completely revised and rewritten.”

Then, as now the subject of our Immigration Laws was the object of much heated debate. In the 1950s, with the Red Scare in full bloom, the fear was mass migration of Communist subversives and assassins – however, then as now there was the racial/ethnic overtone which seems to be really what the debate is always about.

Some of it isn’t so subtle.