ACP: Teasing out science, politics, and emotion about the mammography guidelines

The following is part of a series of original guest columns by the American College of Physicians.

by Steven Weinberger, MD, FACP

ACP: Teasing out science, politics, and emotion about the mammography guidelines It is difficult to find a medical guideline that has garnered so much press and controversy as the recent recommendations about breast cancer screening developed by the U.S. Preventive Services Task Force (USPSTF) and published in Annals of Internal Medicine. Not only have the recommendations about breast cancer screening for women between ages 40 and 49 elicited strong comments and emotional reactions on both sides of the issue from patients and physicians, but they have entered the political arena in unprecedented fashion. In sorting through the different positions and the impact of this paper, several facts need to be kept in mind:

Individualized decision making about screening is sensible. The new guidelines have often been misrepresented as saying that women between ages 40 and 49 should not undergo mammography to screen for breast cancer. In fact, the USPSTF statement is “a recommendation against routine screening of women aged 40 to 49 years.” The Task Force emphasizes that it “encourages individualized, informed decision making about when to start mammography screening.” Therefore, the USPSTF is saying this is not a black-and-white issue, but rather one that justifies an informed decision made by each woman in conjunction with her physician. (Annals of Internal Medicine is seeking physician comments about the guideline to see if it will change practice.)

The guidelines do not recommend that third-party payer coverage be eliminated for screening mammography between ages 40 and 49. Rather, the corollary of individualized decision making on this issue is that coverage should not be denied for those women who decide that they do wish to undergo screening. There is no indication that any third-party payers will deny such coverage, and in fact, the potential backlash from such a decision means it is highly unlikely that such coverage will be eliminated by any payers.

There are many nuances in determining the net benefit of cancer screening. Assessing the net benefit of cancer screening requires a sophisticated analysis, not a knee-jerk reaction that concludes “the more, the better” when it comes to screening. Such concepts as lead-time bias and length bias are unfamiliar to many physicians, let alone the general public. Yet, without a sophisticated understanding of these concepts, the reaction that more screening is better is just an emotional one that can certainly be understood, but not necessarily justified by a hard look at the data.

Breast cancer is certainly not the only cancer for which questions about screening have arisen, as many additional comments have also surfaced about prostate and cervical cancer. We must also remember that screening of high risk patients has not been shown to decrease mortality from lung cancer, the most common cause of cancer death for both men and women in the U.S. Large trials of lung cancer screening are currently underway, and if a critical analysis of new data overturns prior results, then the screening guidelines for lung cancer will appropriately be changed.

The new guidelines were driven by scientific data, not by cost considerations. Although the USPSTF has “US” in its title, its analyses are entirely independent of any governmental influence and are totally based upon the available scientific data. It is clearly incorrect to say that the recommendations represent governmental influence to institute “rationing,” or that cost considerations provided the driving force for the recommendations.

In fact, other guidelines about screening mammography for women ages 40 to 49, developed by the American College of Physicians and published in 2007 in Annals of Internal Medicine, came up with similar recommendations to those of the USPSTF for individualized decision-making about screening of women ages 40-49. The committees that developed the USPSTF and the ACP recommendations are both independent of any external influences and have no relationship to each other.

As with the positions on health care reform, the debate over screening mammography has taken on a heated, emotionally driven life of its own. As these discussions continue, it is important that facts not be distorted, that emotions not trump scientific data, and that scientific rigor not be supplanted by politicization and political considerations.

Steven Weinberger is Deputy Executive Vice President and Senior Vice President, Medical Education and Publishing, of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • Your evidence is weak

    The cost issue is not shibboleth, and “cutting waste” in allocation of health care resources is not only not divorced from the USPSTF’s existence, it is the reason for it.
    The allocation of real dollars, while technically not a consideration they are charged with, is not fully divorced from efficient management of health care dollars in general.

    Under health care reform legislation pending in Congress, the USPSTF recommendations will be used to set reimbursement, and are binding, though Sebelius was quick enough to rush in and remind they aren’t binding NOW. YET.

    I am struck by the frequency with which cost issues are denied, and in the same argument, sometimes the same sentence, followed by a pronouncement that cost cutting is imperative and doctors and patients cannot have “any test or treatment they want”.

    It is about cost. It’s about nothing else, really.
    Any reasonable person would approve tailored care for the individual, with those individuals having a clear understanding of trade-offs made in any treatment decision.
    Also, in this case, the old litmus “Is there ANY mortality benefit” has inexplicably been replaced with “How much are those thousands of lived that we admit are saved worth”

    But the recommendations of USPSTF are based upon mathematical models that used population data that diluted mortality benefit. They ignored some significant live population data showing greater mortality benefit than they found. Without addressing it at all, or saying why – and it’s easy enough to wonder that’s because it got in the way of the preferred outcome of their evaluation.

    They also gave enormous importance to minor considerations of patient “anxiety” and uncomfy biopsy, as if patients cannot or even should not consider these issues themselves.

    THey seemingly give short shrift to, did not consider benefits conferred that might apply in particular to younger populations, and advances in treatment that apply in particular to disease found at earlier stages.

    Stop pretending this isn’t about allocation of resources.
    Because it is.

  • Classof65

    Don’t be fooled — only because there has been heated reaction to the new guidelines are the health insurance companies saying that they never intended to cut funding for mammograms for 40-49 year old patients. Had there been little or no public reaction the insurance companies would have cut payments for those mammos, regardless of familial breast cancer history or the discovery of lumps by the patients.
    Classof65

  • Anonymous

    With regard to the controversial screening tests for breast or prostate cancer, perhaps everyone should think about this question: If you were a normal risk person in the group for which there is controversy about screening (women age 40-49 with respect to mammograms for breast cancer screening, men age 40-75 with respect to prostate cancer screening), would you get the screening if you had to pay for the tests yourself (assuming you are not poor enough that you would have to choose between that and necessities like food, rent/mortgage, etc.)?

  • Xerxes1729

    If you think that concerns about cost and false-positive results shouldn’t be taken into consideration, why don’t we do full-body MRIs on every person in the country every six months. If we did this, we’d catch some things early and be able to save some people who would otherwise have died. I mean, if you oppose it, aren’t you just sentencing those people to die so that insurance companies and the government can save money?

  • A lot of assumptions

    False positives and the physical harms they cause are certainly within the purview of such a panel, if one is to have such a panel. the heavy emphasis on subjective harms such as “anxiety” is a red flag. That subjective harm is something well-informed patients can weigh individually. And if the panel is to consider anxiety, they might consider the new anxiety delayed diagnosis will cause, as a result of patients found larger tumors and worse prognosis will feel.

    They considered mortality. They didn’t consider the reduction in disfiguring surgery or requirements for adjuvant therapy, or advances in early therapy.

    You know their finding have been criticized from the models they used, the data they ignored, the exaggeration of “cost” using subjective measures of emotion and minor discomfort (vs a serious calculable cost such as mortality, disfigurment, etc)

  • Diora

    They didn’t consider the reduction in disfiguring surgery or requirements for adjuvant therapy, or advances in early therapy.

    Except for because of overdiagnosis, there is actually more disfiguring surgery in screened than non-screened women…. As to the requirements for adjuvant therapy, the guidelines for this have been chosen to include more and more women, so a number of “overdiagnosed” cases would certainly get some of it.

    It is amazing to me how everyone who criticizes USPSTF recommendations keep talking about “anxiety” as if it is the only problem. You criticize USPSTF about ignoring this or that yet you deliberately ignore overdiagnosis.

  • Diora

    If you were a normal risk person in the group for which there is controversy about screening (women age 40-49 with respect to mammograms for breast cancer screening,
    I am a normal risk woman and even though I have insurance, I still decided I don’t want mammograms in my 40s, and I will not likely to have them in my 50s either. I’ll take a small risk of dying vs the much higher risk of being unnecessarily diagnosed with cancer and treated and suffer side effects from the treatment. Also, as someone whose blood pressure goes up every time I just need to have a test (and I am not saying about false positives), I feel this “anxiety” everyone is so quick to dismiss would increase my heart disease risk by much more than reduce my risk of dying from breast cancer. Incidentally, keep in mind that this mortality benefit is only breast cancer mortality. No trial has shown any kind of reduction in all cause mortality.

    My guess is that a lot of women would decide against screening if doctors and media hadn’t been lying to them for years about the actual mortality benefit expressed in absolute rather than meaningless relative numbers; also about overdiagnosis and the actual number of women who get false positives. Even recently when discussing new guidelines on TV, the interviewed doctors conveniently forgot to mention overdiagnosis as one of the risks.

  • H

    RE: “would you get the screening if you had to pay for the tests yourself

    Would you support the new screening guidelines if you relied on income from screening and overdiagnosis(assuming you were a radiologist, oncologist or perhaps owned a breast center)?

  • H

    “Had there been little or no public reaction the insurance companies would have cut payments for those mammos, regardless of familial breast cancer history or the discovery of lumps by the patients.”

    …more fear mongering? When I was 30 years of my doctor found a lump in my breast. My insurance company paid for the mammogram even though I was not in the screening group.

  • A lot of assumptions

    H, the lump in your breast would take you out of the average risk patient the screening guidelines apply to.

    The lump puts you in a different category of risk.

  • A lot of assumptions

    I take the American College of Radiology’s , et al’s statements with the financial interest in mind.
    But I also consider that of all interested parties, they will be the ones that look most critically at the science and the conclusions and the assumptions contained in the report. They will be the ones most motivated to point out what others might be tempted to overlook because of THEIR interest.

    The mission of the American Cancer Society and the Breast Cancer Research foundation also varies from that of radiologists, so their criticisms can be compared.

    MSA’S encourage wise use of screening.

  • H

    “H, the lump in your breast would take you out of the average risk patient the screening guidelines apply to.”

    And my insurance company covered the mammogram even though I wasn’t 40 years old. This fear tactic that women at higher risk or those that have a lump are going to be denied a mammogram is just fear mongering…

    “…THEIR interest.” Their financial interest-not my health.

  • Deborah

    I found the Nordic Cochrane Institute’s information sheet on “Mammograms: the risks and benefits” very helpful.
    I was confused by all the conflicting opinions. I’m pleased though I had access to someone like Professor Michael Baum, who first alerted me to a potential problem with breast screening. He was a sole outspoken voice for quite a few years.
    Prof Baum is a senior breast cancer surgeon who helped set up the first UK breast screen clinic. He now believes we need to reconsider screening and the clear evidence of harm and limited benefits. His articles and interviews are available on-line.
    The NCI were highly critical of the brochures porduced by BreastScreen in the UK, Australia and many other countries. They thought they gave women inadequate and misleading information. They called for an immediate re-draft, which has largely fallen on deaf and arrogant ears.
    They decided the issue was so important they should draft their own brochure.
    I’d recommend it to any woman considering mammograms.
    http://www.cochrane.dk/
    They also found insufficient evidence to recommend CBE’s for women of any age…they did not reduce the death rate from cancer, but added considerably to the number of breast biopsies.
    Self-examination is no longer recommended by our doctors or by most medical associations. Once again, it doesn’t help, but causes lots of biopsies for benign things.
    Where does that leave us? Well, that will be different for every woman, but I’ve chosen to be breast aware – just being observant and I’ll report any changes to my Dr.
    IMO, if these things can’t help us or end up hurting us, it’s best to avoid them.

  • A lot of assumptions

    H, again, the guidelines do not apply to women with palpable breast lumps. The guidelines would have no effect on your mammogram coverage even if they were used to set reimbursement for screening (as they would under pending health care legislation).

  • A lot of assumptions

    What about elastography? The new testing for biomarkers? New protocols for management of lumps with benign characteristics?

    Catching early breast cancer AND reducing biopsies are not mutually exclusive propositions.

  • Elizabeth

    I agree with you, Diora.
    I really object to the scare campaigns they direct at women for cervical and breast cancer screening. It does not help to scare women.
    The right approach would be to tell us the truth…benefits and risks and leave us to make the decision.
    If they’re not prepared to do that, if there are bits they have to hide that might put women off screening, then perhaps this test needs a closer look before being released or at the very least, they are the bits we REALLY need to know about….
    This attitude that we’ll talk about the good stuff and hide away the bad stuff is totally unacceptable and it seems to only happen in screening for women. I’ve seen lots of articles in the papers and features on the News about the risks of PSA testing. Not a word on cervical screening and even though many have been concerned about mammograms for many years, it’s only been the last couple of years that women are starting to hear about it.
    Isn’t it curious that we’re always the last ones to be told…when our health is on the line? We’re acting on the assurances of people who choose not to release risk information to us – who tell us half the story.
    Many years later we get the punch line…too late for many women who’ve already been harmed by the test.
    Not good enough….

  • http://dinosaurmusings.blogspot.com/ #1 Dinosaur

    Re: Mammograms for lumps

    Once a woman or her physician finds a breast lump, the mammogram is no longer for “screening” purposes. All third party payers would cover it, as they would any other test to investigate a specific finding. (Although one incredibly irresponsible plan I know refuses to pay for colonoscopy for ANY indication, including rectal bleeding. Mind bending!)

    Misuse of the word “screening” drives me crazy.

  • Diora

    What about elastography? The new testing for biomarkers? New protocols for management of lumps with benign characteristics?

    Catching early breast cancer AND reducing biopsies are not mutually exclusive propositions.

    None of this has been shown to do any good yet, has it? When and if it is, the question could be revisited. Additionally, “a lot of assumptions”, you keep conveniently ignoring overdiagnosis. No testing available today will help you avoid that. In future when and if there are ways to say which cancer would spread, the question can be revisited. Incidentally – if all the money that are used today on scaring women into screening were to be used for research into better treatments and figuring out how to recognize cancers that would spread in woman’s lifetime, maybe more progress would’ve been made.

    You wanted a radiologist opinion. Here is an opinion of a radiologist calling for the truthful information to be given to women written in 2004. Interestingly, the main reason cited for providing more truthful information is malpractice rather than this being the right thing to do. The same radiologist, though, wrote letter to the editor of Chicago Tribute in defense of Elizabeth Edwards at the time of her diagnosis of breast cancer, when every newspaper and every busybody was writing editorials on how irresponsible it was for her to have skipped mammograms. It’s long past time for women to be told the full truth.

  • A lot of assumptions

    Actually it has been shown to “do good”. Check out the Medpage links up and to the right for very recent discussions of all of the above.

  • Diora

    A lot of assumption – you still conveniently ignore the issue of overdiagnosis. Also if these things are shown to “do good” – the articles talk about “potential” not what is happening today in general practice; the studies are preliminary. When and if it is actually going to be part of general practice then the issue can be re-visited.

    And again, why do you keep ignoring the issue of overdiagnosis? Do you even understand it?

  • http://pulse.yahoo.com/_SQVOWLFFBQ32YWRTFB5KBENIVE Eliz52

    More damning evidence: a recent study that shows the fall in the death rate from breast cancer is about better treatments, NOT screening. Prof Michael Baum, UK breast cancer surgeon has called for the program to be halted – a legal action is also being commenced by a group of doctors against the NHS for failing to obtain informed consent for women.
    The old double standard is alive and well – women get spin and an order to screen to achieve govt set targets to justify hugely expensive programs – coercion is even used in the States – I’ve heard some doctors require women to have breast screening and a host of other unnecessary, unrelated and potentially harmful exams and tests to get birth control or HRT….just shocking! – while men get the facts and have a say in prostate cancer testing.
    It’s time to get rid of these unacceptable attitudes and practices – women are adults – no one has the right to make decisions for us or accept risk on our behalf.
    http://www.guardian.co.uk/commentisfree/2011/aug/02/breast-cancer-screening?commentpage=3#start-of-comments
    http://www.bmj.com/content/343/bmj.d4411