Should the USPSTF include specialists?


The United States Preventive Services Task Force (USPSTF) was created by the federal government in 1984 to provide recommendations to primary care practitioners on the scientific efficacy of screening. In 2010, the federal government linked USPSTF recommendations with national healthcare policy when the Affordable Care Act mandated free coverage by Medicare and private insurance for all screening exams that receive a USPSTF recommendation of A or B.  The law was intentionally silent regarding coverage for services that receive USPSTF grade C, D or I (insufficient evidence) recommendations.  Insurers can cover these services but have no mandate to do so.

The link between USPSTF recommendations and insurance coverage has become highly controversial, especially in the case of cancer screening. The controversy is fueled by the fear that patients may lose access to cancer screening exams that do not receive USPSTF A or B recommendations. Thus, it is critical that USPSTF recommendations are based on the best expert opinions.

How many cancer experts are on the USPSTF?  Zero.  No cancer expert — whether oncologist, radiation oncologist, surgeon, radiologist, nuclear medicine specialist, or pathologist — has ever been a member of the USPSTF.

The 16 USPSTF members are appointed exclusively from primary care physicians or nurses with expertise in public health and/or clinical prevention.  This makes sense from a historical perspective.  The USPSTF was created in the 1980s to provide summaries of medical research to a primary care audience with no direct impact on screening policy until the Affordable Care Act.

In defense of the USPSTF, they utilize sophisticated national network run by public health experts called the Evidence-based Practice Centers (EPC) that provide the USPSTF with summary reports of medical literature.   However, these public health experts do not have the experience and knowledge of cancer specialists.

The exclusion of cancer specialists has been problematic for the USPSTF, perhaps best illustrated by recent USPSTF recommendations on screening mammography.  A firestorm erupted in 2009, and again in 2016, when the USPSTF gave a C grade recommendation to annual mammograms for women 40 to 50 years of age and a B grade recommendation for obtaining a mammogram every-other-year (instead of yearly) for women 50 to 74 years old.  Consequently, women over 40 would no longer be guaranteed a screening mammogram until a decade later, and women over 50 would only be guaranteed screening mammography every-other-year.

Because these recommendations directly conflicted with American College of Radiology and National Cancer Institute recommendations, women received mixed messages regarding when to obtain screening mammography. Conflicting opinions in prestigious medical journals added to the confusion.  Many in the breast cancer community — both patients and physicians — strongly protested that their voices were not represented by the USPSTF.  Many breast cancer specialists felt excluded by the USPSTF — and, by law, they were.

The end result was this: Congress enacted legislation in 2009, and again in 2016, to override the USPSTF recommendations on mammography.  Should Congress overturn the findings of an independent scientific body like the USPSTF?  Some argue that this Congressional action may save thousands of women’s lives.  Others feel that political interference with scientifically grounded policy sets a bad precedent and is a violation of public trust and an overall threat to women’s health.

That Congress felt compelled to intervene may suggest that USPSTF recommendations did not incorporate expert opinions from all sides and were therefore too polarizing.  Indeed, experts within and outside of a specific field may interpret the same scientific evidence differently because their experiential and technical understanding of key issues differ.  In the case of screening mammography, public health experts justifiably favor studies performed over decades as these are best designed to show whether screening saves lives.  On the other hand, breast cancer experts look at these same studies and conclude that the mammography techniques and breast cancer treatments from the 1980s and 1990s poorly reflect our current capabilities.  Every viewpoint adds value and all should be incorporated to reach the most up-to-date and accurate interpretation of medical evidence.

Importantly, legislation to provide more inclusive USPSTF membership and recommendations is currently under consideration by Congress (i.e., the USPSTF Transparency and Accountability Act of 2015).  This legislation would do the following:

  1. Mandate that USPSTF membership include balanced representation of primary care and specialist providers.
  2. Require USPSTF recommendations to be reviewed by specialists that treat the specific disease under review before a final vote is made.
  3. Create an advisory board including clinical experts, patient advocacy groups, and scientific agencies like the National Cancer Institute and National Institutes of Health that would provide feedback on USPSTF draft recommendations.
  4. Require the USPSTF to compare recommendations with those of relevant national medical professional societies.
  5. Perform yearly analysis on whether USPSTF recommendations worsen morbidity, mortality or patient access to screening.

This legislation would provide more inclusive USPSTF membership, introduce processes that incorporate expert opinions from all sides into USPSTF recommendations, and monitor whether USPSTF recommendations harm patients.  USPSTF recommendations have the power to guarantee access to screening exams for all Americans.  Balanced and inclusive recommendations founded on combined public health, primary care and specialist expertise should be assured.  No single group — whether primary care or specialists — should have the only voice for something as important as national cancer screening.  For this reason, the USPSTF must change.

Matthew F. Covington and Phillip H. Kuo are radiologists.

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