Paying women to have mammograms is unethical, ethicist says

September 10, 2015 by Katie Delach, University of Pennsylvania School of Medicine
Credit: National Cancer Institute/public domain

The widespread practice of incentivizing mammogram completion via cash payments, typically by insurance companies and ranging from $10 to $250, is unethical according to a Viewpoint article published this week in JAMA by an expert from the Perelman School of Medicine at the University of Pennsylvania. Instead, incentives should be offered to women to use evidence-based decision aids to decide if they want a mammogram, even if this policy likely averts fewer breast cancer deaths overall.

In the piece, Harald Schmidt, PhD, assistant professor of Medical Ethics & Health Policy, notes that are increasingly used to promote healthy behaviors such as quitting smoking and losing weight. In such cases, Schmidt says achieving the incentivized targets produces health and financial benefits without any risks. But other incentivized health behaviors, such as screenings, are different.

"Incentives for having are ethically troubling," says Schmidt. "Women need to strike a delicate balance in assessing the benefits and risks of mammograms. In the case of smoking cessation or weight loss programs, providing incentives supports behavior change. But with , mammograms can unhelpfully short-circuit decision-making."

Schmidt points out that incentives can wrongly signal mammograms as beneficial only, and offers several reasons for concern. First, not all screened women benefit, since although screening reduces chances of dying from breast cancer, there are screened women who nonetheless die from the disease. Second, some cancers identified in screening never develop into lethal tumors. "These cases of over-diagnosis regularly lead to over-treatment," he said. This includes partial or full surgical breast-removal and hormone-, radio-, or chemotherapy. Third, all participants risk periods of worry due to false positives and biopsy complications.

There is general agreement that benefit-risk ratios differ significantly across age groups. The U.S. Preventive Service Task Force's screening guidelines recommend mammograms every two years for average-risk women aged 50- to 74 years with a "grade B" screening, due to "moderate certainty that the net benefit is moderate." For ages 40- to 49 years, a weaker grade C recommendation is made: "There is moderate certainty that the net benefit is small." Broadly, the Task Force recommends making screening decisions on an individual basis.

Schmidt NOTED that in a study assessing decision aids, women receiving brochures which explicitly enumerated risks and benefits of mammograms (such as the actual number of false positives that patients received) were less inclined to have mammograms—74 percent vs. 87 percent—than women who received brochures simply discussing the risk of false positives, but without actual figures to illustrate the scope of overtreatment.

"Findings such as these can pose a dilemma for policy-makers," said Schmidt. "Informed decision-making is important. But since better-informed women are less inclined to be screened, fewer breast cancer deaths will likely be averted. The question is: should minimizing deaths from breast cancer be prioritized over maximizing informed decision making, or vice-versa?"

Schmidt writes that true consent demands an understanding of an intervention's risks as well as benefits. Consequently it is unethical to omit pertinent information, such as false-positive rates and information on overtreatment. And because of the complexity of the data, information should be conveyed in ways that are understandable by patients of all levels of literacy and numeracy.

"Incentives," he writes, "should support, and not distract—or worse, undermine—informed decision-making. Completion incentives that inevitably signal mammograms as inherently valuable are unhelpful in this regard and should be phased out, especially for ages younger than 50."

Furthermore, "Less educated, lower-income groups face greater challenges because incentives, especially larger financial ones, have more salience for them and may unhelpfully shortcut informed decision-making … In addition to insufficient respect for their autonomy, the disproportionately higher economic and psychological burden associated with possible harms from screening must be especially concerning." The bottom line, he concludes, is that "[m]ammogram choices should be made by meaningfully informed women – not their physicians, health plans, policy makers, or other parties."

Explore further: False-positive mammogram result traumatic for most women, study finds

More information: "The Ethics of Incentivizing Mammography Screening." JAMA. 2015;314(10):995-996. DOI: 10.1001/jama.2015.8852

Related Stories

False-positive mammogram result traumatic for most women, study finds

August 26, 2015
(HealthDay)—In a finding that won't surprise many who've been through this ordeal, researchers say emotional turmoil is common for women whose mammogram falsely suggests they have breast cancer.

Better informed women less likely to want a breast mammogram

February 17, 2015
Women who understand the risk of over-detection and over-diagnosis associated with mammography screening have lower intentions to have a breast screening test, according to a new Lancet study.

New breast cancer screening analysis confirms biennial interval optimal for average risk women

April 20, 2015
Results from a second comprehensive analysis of mammography screening, this time using data from digital mammography, confirms findings from a 2009 analysis of film mammography: biennial (every two years) screening offers ...

Radiation from mammograms may be lower than thought

July 15, 2015
(HealthDay)—The low risks from radiation exposure during mammography screening may be even lower than experts have assumed, a new study contends.

What age should women start mammograms? The two sides of the screening debate

November 1, 2013
Mammography works: It can detect cancer. On that point, at least, most experts agree.

Doctors, women should spend more time discussing mammograms

August 9, 2011
Due to changing guidelines concerning when and how often they should first be screened for breast cancer with mammograms, many women are confused. The American Cancer Society recommends women 40 years and older get a mammogram ...

Recommended for you

New approach attacks 'undruggable' cancers from the outside in

January 23, 2018
Cancer researchers have made great strides in developing targeted therapies that treat the specific genetic mutations underlying a patient's cancer. However, many of the most common cancer-causing genes are so central to ...

Study: Cells of three advanced cancers die with drug-like compounds that reverse chemo failure

January 23, 2018
Researchers at Southern Methodist University have discovered three drug-like compounds that successfully reverse chemotherapy failure in three of the most commonly aggressive cancers—ovarian, prostate and breast.

'Hijacker' drives cancer in some patients with high-risk neuroblastoma

January 23, 2018
Researchers have identified mechanisms that drive about 10 percent of high-risk neuroblastoma cases and have used a new approach to show how the cancer genome "hijacks" DNA that regulates other genes. The resulting insights ...

Enzyme inhibitor combined with chemotherapy delays glioblastoma growth

January 23, 2018
In animal experiments, a human-derived glioblastoma significantly regressed when treated with the combination of an experimental enzyme inhibitor and the standard glioblastoma chemotherapy drug, temozolomide.

Researchers identify a protein that keeps metastatic breast cancer cells dormant

January 23, 2018
A study headed by ICREA researcher Roger Gomis at the Institute for Research in Biomedicine (IRB Barcelona) has identified the genes involved in the latent asymptomatic state of breast cancer metastases. The work sheds light ...

Boosting cancer therapy with cross-dressed immune cells

January 22, 2018
Researchers at EPFL have created artificial molecules that can help the immune system to recognize and attack cancer tumors. The study is published in Nature Methods.

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.