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

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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