On the politics of cancer screening – a case of governance?

thOn a regular basis newspaper articles appear calling for more and less screening for various diseases, notably cancer.  Just this week I came across two on breast cancer screening.  One, in the New York Times, was sceptical of the merits of mass screening raising the very real risks associated with false positives.  On the argument that “overtreatment is typically more common than avoiding a cancer death” H. Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, calls for more research to develop a finer grained understanding of the risks and the benefits of breast cancer screening.  A second article in the Huffington Post took issue with the claims of Dr. Welch, making the case for continuing emphasis on screening. (For an excellent overview of the evidence on breast cancer screening – albeit arguing for less screenign – see here).

What I find most interesting about these debates is that governments try hard not to get directly involved.  In the spirit of medicine as a self-regulating profession, most governments offer citizens limited advice and we told to discuss our options with our doctor.  (There are some interesting exceptions when, for example, a provincial government (in this case Ontario) actively promotes breast cancer screening while refusing to pay for PSA tests except where a physician or nurse practitioner suspects prostate cancer. For an excellent primer on prostate cancer screening see here.)

Prostate_Cancer_ScreeningsOccasionally, a task force or advisory body will release new guidelines for screening and a spirited if not vociferous debate ensues as different groups weigh in arguing the new recommended guidelines are too lax or too strict.  In 2012, for example, the U.S. Preventive Service Task Force issued a new set guidelines for the screening of prostate cancer. The Task Force took a dim view of PSA tests which precipitated a very strong reaction from the American Urological Association.  And less than two years later Prostate Cancer Canada issued its own set of guidelines calling for more rather than less use of the controversial PSA test.  This underlines the fact that there are, in fact, a plethora of guidelines issue by different authoritative groups.  Sometimes they are similar, very often they differ in important ways, and occasionally they are contradictory.

What is the citizen/patient to make of all of this?  I am not sure.  But it seems to me that cancer screening is a potentially useful area for political scientists interested in governance, policy networks, and the general trend of authoritative rule making by entities other than elected governments.

Now the search begins for a good model of non-state governance that would contribute to the systematic study of health sector governance in general and, in particular, the politics of cancer screening.  Suggestions welcome.

Governance

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