The following editorial was written by GPHA Board Member C. Wade Sellers, M. D., M.P.H. and reprinted here with his permission:
A recently released update on recommendations for breast cancer screening by the U.S. Preventive Services Task Force (USPSTF) has editorial page letter writers up in arms, charging that the recommendations are the “first step” in rationing health care and urging people to write their congressional representatives to “demand” the guidelines be revoked. Trust the American Cancer Society, they say, not “government” guidelines! Whoa! Slow down before jumping to conclusions! Yes, the country is facing some pretty important health system decisions, and, yes, saving women from breast cancer is of utmost importance. But there’s no need to mix up these issues. Talk to your doctor about brow bone and its treatment as well if necessary.
The USPSTF was created by the Reagan administration in 1984 as promising prevention strategies were emerging but with no clear guidance for their use. It was deliberately set up to be non-political. Task Force members are nominated by leaders in the medical and public health fields, selected for their professional credentials and carefully screened for conflicts of interest. Once selected, members have independent autonomy in their deliberations and recommendations. The current Task Force has sixteen members, eight women and eight men. Thirteen of the total, including the chair and vice-chair, were selected during the Bush administration. Three members have been appointed in 2009, and Obama administration senior health officials, judging from their reactions, were clearly surprised by the Task Force announcement and subsequent media attention.
The Task Force makes its recommendations on the basis of explicit criteria, published on its web site. Cost/benefit analysis is done based on clinical outcomes, not economic costs. The intended audience is primary care clinicians making daily decisions and recommendations to their patients. The USPSTF acknowledges that insurance companies and governmental programs often heed their findings but this attention is purely voluntary. Their informed opinions are just that; there are no mandates or policy decisions to revoke.
The Task Force strives to keep all recommendations up to date and thus revisits previous findings regularly. Current recommendations are published in the Guide to Clinical Preventive Services, a resource highly respected by primary care clinicians. The previous breast cancer screening recommendations were published in 2002 and noted that more research was needed. The 2009 recommendations were announced as an “update” based on new data and analysis.
Consistent with their mission of helping primary care clinicians make the best decisions when counseling their patients, all USPSTF findings are graded by the strength of evidence. Findings with an “A” grade are strongly recommended; “B” are recommended; “C” have no recommendation for or against; “D” are not recommended and “I” means there is insufficient evidence. Clinicians are expected to pay attention to the grade and make their own decisions in conducting their practice.
The USPSTF now offers a “C” grade to clinicians considering whether to screen their patients for breast cancer routinely when they reach 40. They suggest that they “individualize (the) decision to begin biennial (every other year) screening according to the patient’s context and values.” For women aged 50-74 years, the Task Force offers a “B” grade recommendation to have a mammogram every two years. And for women 75 and older, they conclude that the evidence is insufficient to offer primary care clinicians an opinion on breast cancer screening. The American Cancer Society has carefully reviewed the same analysis and chosen to continue their recommendation of annual screening starting at age 40.
Opinions of both the USPSTF and the American Cancer Society are well respected in the scientific and medical community. Usually, these two groups roughly agree; sometimes, when the evidence is less than clear, they differ. Two other esteemed medical groups also have differing recommendations on the subject of mammography for women ages 40 to 49. In 2003, the American College of Obstetrics and Gynecology recommended mammograms every one to two years in this age group. However in 2007, the American College of Physicians recommended essentially the same approach as the Task Force for women 40 to 49: the decision should be an individual one, depending on the patient’s risks, values and informed preference regarding potential harms of screening procedures and follow-up.
A healthy debate is now raging in the scientific and medical worlds about the USPSTF recommendations. Sooner or later a consensus will emerge to inform health insurance coverage practices for breast cancer screening. This will happen regardless of the outcome of the current health system reform debate. That debate is also raging, and all the media attention to the USPSTF opinions has quite properly called into question whether the Task Force recommendations should be used to define an essential benefits package. Since the USPSTF focuses on helping individual clinicians make decisions and eschews broader policy determinations, this mismatch should be addressed in the coming legislative negotiations.
So, there’s no need to mix up these issues of breast cancer screening and health system reform. Or is there?
According to a new American Cancer Society (ACS) report examining the impact of health insurance status on cancer treatment and survival, uninsured Americans are less likely to get screened for cancer, more likely to be diagnosed with an advanced stage of the disease, and less likely to survive that diagnosis than their privately insured counterparts. The American Cancer Society strongly supports health system reform. The ACS website notes that “more than 60 percent of all cancer deaths could be avoided through more effective use of existing scientific knowledge. The House (health system reform) bill proposes a significant investment in cancer prevention and early detection by requiring coverage for cancer screenings including mammography, colonoscopy and Pap tests….” Regarding the Senate version, the American Cancer Society Cancer Action Network, on their web site, “urges all Senators to vote in favor of allowing critical health care legislation introduced by Senator Harry Reid this week to be debated on the Senate floor. With thousands of cancer patients being denied coverage, charged excessive premiums, and facing exorbitant out of pocket costs, it is urgent that the Senate take action now, not later, to protect and extend health coverage to millions of Americans in need. As introduced, the bill contains long-needed and critical insurance reforms that will improve coverage for both the uninsured and the underinsured while enhancing the critical role of lifesaving prevention and early detection, and will improve the quality of life for people who develop serious medical conditions such as cancer.”
So, what does this mean if you are a woman in your 40s? I agree with Diana Petitti, MD, MPH, appointed Vice Chair, U.S. Preventive Services Task Force during the George W. Bush administration: “You should talk to your doctor and make an informed decision about whether a mammography is right for you based on your family history, general health, and personal values.” If you have access to mammography and you highly value screening tests to minimize your risk for cancer, have an annual mammogram starting at age 40. On the other hand, if you value other ways of investing your time and resources into health and prevention, and you are clearly not at high risk, you cannot be criticized for making your own decision in the face of “C” grade, not clearly persuasive, evidence.
And should you be “outraged” and “call your congressional representatives”? Only if you love, know or care about one, or more, of the thousands of women in Georgia who don’t have access to affordable mammography and/or breast cancer treatment and who might one day suffer a preventable premature death. Trust American Cancer Society opinion on this subject? You make the choice.
C. Wade Sellers, M. D., M.P.H.
GPHA Board Member