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.
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.)
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.
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?
- Susan G. Komen Foundation Illustrates Hypocriscy At Its Finest (geekmadel.com)
- Susan G. Komen Foundation Backs Down On Cutting Off Planned Parenthood (brandtstandard.com)
- Komen reverses course after uproar (cbsnews.com)
- Komen Apologizes, Reinstates Planned Parenthood Funding (littlegreenfootballs.com)
- Komen Foundation reverses funding decision of Planned Parenthood (cnn.com)
- Komen’s Race To Reverse Course: Questions And A PR Challenge (npr.org)