Duck and Uncover

This week, the Susan G. Komen Foun­da­tion, one of the best-​​funded, most vis­i­ble, and most pow­er­ful orga­ni­za­tions gath­er­ing money for breast can­cer treat­ment, research and screen­ing, stepped in a big pile o’ poo when they changed their grant appli­ca­tion rules in such a way to rather point­edly exclude Planned Parenthood.

Planned Par­ent­hood is not the Komen Foundation’s biggest prob­lem, though. As you’ll see shortly, they spend their money on feel-​​good projects, rather than using evidence-​​based med­i­cine to deter­mine who will be funded. In fact, there are sev­eral instances where Komen part­ner­ships have been detri­men­tal to women’s breast health. They have always made their deci­sions based on pol­i­tics and appear­ances, not what’s best for women.

The move to bar Planned Par­ent­hood was in response to anti-​​abortion groups, who objected to Planned Parenthood’s fund­ing of abor­tions. The media frenzy exposed some­thing that many in the med­ical and research com­mu­nity have known for some time: health care is polit­i­cal, and the Susan B. Komen Foun­da­tion is heav­ily staffed with peo­ple who iden­tify with con­ser­v­a­tive pol­i­tics. Most attrib­uted the cur­rent cri­sis to the hir­ing of Senior Vice Pres­i­dent for Pub­lic Pol­icy Karen Han­del nine months ago.

Ms. Han­del describes her­self in her Twit­ter pro­file as a “Life­long Con­ser­v­a­tive Repub­li­can” and for­mer Geor­gia Sec­re­tary of State. She would seem to be well-​​suited to a role involv­ing cri­sis man­age­ment for a large, high-​​profile national organization.

But, con­trary to her name, Ms. Han­del didn’t han­dle the cri­sis very well, as evi­denced by the oft-​​cited retweet shown at right.

Behind its happy face, with pink rib­bons all around and walks and sur­vivor speeches, the Komen Foun­da­tion clearly has had an empha­sis on politics.

Breast can­cer affects one in eight women at some point in their life­time. There are few peo­ple who haven’t been touched by breast can­cer. For exam­ple, my mother, my boss, and my boss’s boss all have been diag­nosed with breast cancer.

Breast can­cer has been a polit­i­cal hot potato for a long time. For instance, from the mod­er­ate left, Sen­a­tor Tom Harkin (D-​​IA), who had two sis­ters who died of breast can­cer, has diverted large sums of money (e.g., $210 bil­lion in fis­cal 1993) from the national defense bud­get to breast can­cer research. For rea­sons of fed­eral bud­getary trans­parency alone, this is a bad idea, and it was never clear that the Depart­ment of Defense (DoD) was equipped to screen appli­ca­tions for breast can­cer research and treat­ment grants. (I was a reviewer for a DoD pro­gram that was the ben­e­fi­ciary of a sim­i­lar diver­sion of funds for head injury research, and the fund­ing process at that time was pretty Byzantine.)

A drop in the pink bucket.

In the rush for fund­ing and vis­i­bil­ity, the Komen Foun­da­tion some­times finds itself in strange brand­ing eddies and pools. For exam­ple, there’s one that always bugged me, the KFC bucket of chicken with the pink rib­bon on it. This pro­mo­tion gen­er­ated $4.2 mil­lion for the Komen Foun­da­tion, the largest sin­gle check in the organization’s his­tory. Yet breast can­cer costs the United States $14 bil­lion per year in direct med­ical costs alone. If KFC does some­thing to increase the national breast can­cer risk by just three hun­dredths of a per­cent (4.2 mil­lion ÷ 14 bil­lion), then they’re cost­ing the Amer­i­can peo­ple more than they’re help­ing the Komen Foundation.

A bucket of KFC con­tains 1,725 calo­ries and almost a hun­dred grams of fat. That’s an entire day’s worth of calo­ries for an aver­age per­son and about twice the max­i­mum amount of fat one should eat in a day. Con­sump­tion of KFC every day would almost cer­tainly result in obe­sity, and obe­sity is a major risk fac­tor for breast can­cer. Sim­ply put, the more breast tis­sue one has, the greater the chance of can­cer some­where in that larger tis­sue mass. Fat also acts as an endocrine (hormone-​​secreting) organ that changes a woman’s phys­i­ol­ogy. It would be an inter­est­ing exer­cise to cal­cu­late the costs to soci­ety of the KFC bucket ver­sus the amount of money donated by KFC to the Komen Foun­da­tion. I’m will­ing to wager that reg­u­lar con­sump­tion of KFC increases breast can­cer inci­dence by more than three hun­dredths of a percent.

Another dis­cus­sion we should be hav­ing has been buried under an avalanche of pub­lic­ity in the Komen vs. Planned Par­ent­hood cage match. Is fund­ing Planned Par­ent­hood screen­ing pro­grams through Komen a good idea — med­ically, eco­nom­i­cally, or both?

Most peo­ple would con­sider screen­ing tests such as mam­mog­ra­phy to be an essen­tial part of fight­ing breast can­cer. How­ever, screen­ing tests come with their own risks. One of the great­est risks in terms of money and emo­tional energy spent is what is called a “false pos­i­tive”: a test that appears to detect can­cer when no can­cer is present. As any­one who has had a false pos­i­tive can­cer test can tell you, there is a tremen­dous emo­tional drain on some­one who has a puta­tive can­cer diag­no­sis hang­ing over their head. It’s dif­fi­cult to cal­cu­late those costs, but even if one only con­sid­ers the cost of the fol­lowup biopsy or other tests and care, too much screen­ing can be a drain on the health care sys­tem as well.

To bet­ter under­stand this, imag­ine that we screened all 14-​​year-​​old girls for breast can­cer. We would find almost no can­cer in this pop­u­la­tion, less than one in a mil­lion, but if we screened a mil­lion 14 year olds each year and had a small false pos­i­tive rate (say, a tenth of a per­cent, which is one in every thou­sand) then we would still need to do costly fol­lowup on a thou­sand girls and would detect zero cancers.

This pro­duces a counter-​​intuitive result for some peo­ple. When the United States Pre­ven­ta­tive Screen­ing Task Force (USPSTF) issued a 2009 rec­om­men­da­tion that most women under 50 or over 75 did not need breast can­cer screen­ing, there was a tremen­dous out­cry, sim­i­lar to the anti-​​Komen out­cry we heard this week. The same USPSTF panel rec­om­mended that doc­tors not teach women the tech­nique of breast self-​​examination, for the same rea­sons. We have been told repeat­edly that can­cer screen­ing saves lives. Yet, the USPSTF says not to screen women 40 to 49 with no known risk fac­tors for breast can­cer. Why wouldn’t we want to screen all 40– to 50-​​year-​​old women? Sim­ply put, the risk from can­cer for most women in this age group (unless there is a strong fam­ily his­tory of can­cer or other rea­son to screen) is minis­cule com­pared to the false pos­i­tive rate. We will detect very few can­cers … and incon­ve­nience a lot of women.

Human minds tend to over-​​emphasize a small prob­a­bil­ity of a high-​​risk event and under-​​emphasize a larger prob­a­bil­ity of a less cat­a­strophic event. Thus, peo­ple worry about a plane crash but don’t worry about car crashes, even though car crashes are much more com­mon (by sev­eral orders of mag­ni­tude) than plane crashes. So it is with breast can­cer for women under 50 in women with no fam­ily his­tory of breast dis­ease, but the issue is fuzzy enough to cause a lot of anxiety.

While the life­time risk of breast can­cer is one in eight, as I stated above, the risk is high­est for women between 50 and 70. From the National Can­cer Insti­tute:

A woman’s chance of being diag­nosed with breast can­cer is:

  • from age 30 through age 39 .… . . 0.43 per­cent (often expressed as “1 in 233″)
  • from age 40 through age 49 .… . . 1.45 per­cent (often expressed as “1 in 69″)
  • from age 50 through age 59 .… . . 2.38 per­cent (often expressed as “1 in 42″)
  • from age 60 through age 69 .… . . 3.45 per­cent (often expressed as “1 in 29″)

Screen­ing is very impor­tant, but it must be tar­geted to the right age group. So, we need to ask if the cost due to a false pos­i­tive rate for screen­ing in the 40 to 49 age group exceeds the ben­e­fit to the one in 69 women in that age group who will be diag­nosed with breast cancer.

Source: National Can­cer Institute

Sim­i­larly, it’s impor­tant to screen low-​​income women, yet those are the women less likely to receive rou­tine mam­mo­grams every two years between 50 and 75, as rec­om­mended by the USPSTF. The graph at right shows the dis­par­ity between screen­ing of low-​​income and high-​​income women.

Planned Par­ent­hood is screen­ing low-​​income women, yet not fol­low­ing the USPSTF guide­lines. Accord­ing to the linked Wash­ing­ton Post story, most women who visit Planned Par­ent­hood clin­ics get a phys­i­cal breast exam rather than a mam­mo­gram. Low-​​income women of child­bear­ing age (i.e., under 45) are the most likely to visit a Planned Par­ent­hood clinic, yet these women are not at par­tic­u­larly high risk of breast can­cer. (Impor­tantly, they also get a Pap smear, a crit­i­cal test for detec­tion of cer­vi­cal can­cer, which is more com­mon in this age and socioe­co­nomic group.) The role of Planned Par­ent­hood in pro­vid­ing some kind of base­line med­ical care to these women is much greater than its role in detect­ing breast can­cer, the stated aim of the Komen Foundation.

The cur­rent brouhaha between the Komen Foun­da­tion and Planned Par­ent­hood is just a micro­cosm of the con­tin­u­ing debate over the cost vs. ben­e­fit of pro­vid­ing health care in this coun­try. The polit­i­cal sturm und drang is really just a sideshow, a magician’s trick to divert your atten­tion. As a savvy Log­a­rchism reader, you should focus on the real issue: what rou­tine tests are worth pay­ing for, espe­cially if the tax­payer (or char­ity donor) foots the bill? Are both the Komen Foun­da­tion and Planned Par­ent­hood miss­ing the boat?

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