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 Sept. 8 in JAMA by an expert from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. 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, according to the article.
In the piece, Harald Schmidt, PhD, assistant professor of medical ethics & health policy at Perelman, said cash payments are increasingly used to promote healthy behaviors such as quitting smoking and losing weight. In such cases, achieving the incentivized targets produces health and financial benefits without any risks, Schmidt said in the article. But other incentivized health behaviors, such as breast cancer screenings, are different.
“Incentives for having mammograms are ethically troubling,” Schmidt said in the article. “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 breast screening, mammograms can unhelpfully short-circuit decision-making.”
Schmidt said incentives can wrongly signal mammograms as beneficial only. Not all screened women benefit, he wrote, since although screening reduces chances of dying from breast cancer, some screened women nonetheless die from the disease. In addition, some cancers identified in screening never develop into lethal tumors, he wrote.
“These cases of over-diagnosis regularly lead to over-treatment,” he said in the article, referring to partial or full surgical breast removal and hormone therapy, radio therapy and chemotherapy. All participants risk periods of worry due to false positives and biopsy complications, he said in the article.
The U.S. Preventive Service Task Force’s screening guidelines recommend mammograms every two years for average-risk women ages 50 to 74 with a grade B screening, due to “moderate certainty that the net benefit is moderate.” For ages 40 to 49, 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 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 should support, and not distract — or worse, undermine — informed decision-making,” he wrote, adding completion incentives should be phased out, especially for women ages 49 and younger.
He also stated that less-educated, lower-income groups may have mammograms based on economic issues rather than informed decision making. The bottom line is that “mammogram choices should be made by meaningfully informed women, not their physicians, health plans, policy makers or other parties,” he wrote.