What if a non-partisan, authoritative entity wrote a robust, evidence-based guideline, but nobody followed it?
That is precisely what’s happening with the USPSTF’s recent revision of their breast cancer screening recommendations. The change most find problematic is their recommendation that women younger than 50 not undergo any breast cancer screening, such as with a mammogram.
Here are their reasons explaining why:
The harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results. Furthermore, one must also consider the harms associated with treatment of cancer that would not become clinically apparent during a woman’s lifetime (overdiagnosis), as well as the harms of unnecessary earlier treatment of breast cancer that would have become clinically apparent but would not have shortened a woman’s life. Radiation exposure (from radiologic tests), although a minor concern, is also a consideration.
Adequate evidence suggests that the overall harms associated with mammography are moderate for every age group considered, although the main components of the harms shift over time. Although false-positive test results, overdiagnosis, and unnecessary earlier treatment are problems for all age groups, false-positive results are more common for women aged 40 to 49 years, whereas overdiagnosis is a greater concern for women in the older age groups.
They’re completely right, of course. As I previously wrote in a USA Today op-ed on this issue, “For every inspiring story of a person cured from cancer made possible by early detection, there are untold stories of many more who suffer from the side effects of unnecessary invasive procedures stemming from false positive test results.”
But some patients are rebelling against these new guidelines, as noted in this article from The New York Times, New Mammogram Advice Finds a Skeptical Audience. A few doctors, too, are refuting the new recommendations as well. Suspiciously, they are mostly radiologists and oncologists. Cynics may wonder whether there is a financially-motivated basis for their dissent.
What’s fascinating is how mammogram screening has now turned rabidly political, with conservatives making the ridiculous link to “rationing.” And Kathleen Sebelius, the secretary of health and human services, tried to distance herself from the USPSTF, stressing that, “I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action,” and that, “our policies remain unchanged.”
What, then, is the point of making any guidelines at all, if our government urges everyone to ignore them?
Progressive reformers, who generally espouse comparative effectiveness data and evidence-based medical practice as a means to control costs, should be very worried about the backlash these guidelines are eliciting.
If recommendations from an entity like the USPSTF – as non-partisan and robust as it gets – gets so much resistance from doctors, patients, and even the government itself, findings from a comparative effectiveness body stand absolutely no chance of changing medical practice.
