Navigating the tempest over breast cancer screening

Navigating the tempest over breast cancer screening
Navigating the tempest over breast cancer screening

Rarely has as much ink been spilled and as many electrons sent flying over guidelines as there were over the US Preventive Services Task Force's November 16, 2009, update and recommendations on breast-cancer screening.1

The Task Force members—primary care physicians and epidemiologists chosen and funded by the Department of Health & Human Services' (DHHS) Agency for Healthcare Research and Quality—gave a Grade C recommendation against routine screening mammography in women aged 40 to 49 years. This means clinicians advising mammography for their patients must consider additional factors, such as the woman's personal risk of breast cancer.

This recommendation was based on an accompanying literature analysis and computer modeling. The results indicated that 1,904 screening mam­mograms would need to be performed among women aged 39 to 49 years to prevent one breast cancer death in this age group (Table 1).2 In contrast, 1,339 mammograms would be needed to prevent one such death in women 50 to 59 years, and just 377 would be needed in women 60 to 69 years. The analysis also pointed to the very high false-positive rate among younger women and the toll exacted by such factors as the pain and radiation exposure associated with mammography.

The Task Force members recommended that women aged 50 to 74 undergo biennial rather than annual screening and recommended against teaching women how to perform breast self-examination. Amid the media uproar that followed, many members of the medical and lay communities expressed concerns about potential rationing of mammography.

THE FUROR

Groups such as the American College of Radiology (ACR) and the Republican Party fanned the flames by charging that the recommendations were primarily geared toward such rationing. Hence, they could cause "countless" breast cancer deaths, according to the ACR.

DHHS Secretary Kathleen Sebelius issued a public statement responding to the furor by saying, "Our policies remain unchanged. Indeed, I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action." She also distanced herself from the recommendations and seemed to agree that they were politically motivated by telling CNN, "This panel was appointed by the prior administration, by former President George [W.] Bush." (Editor's note: the Task Force has been in existence since 1984, with members appointed by all presidents since that time.)

Meanwhile, legislation that is before the US Senate would have allowed insurance companies to use discretion on covering preventive screening or other procedures that receive a Grade C or lower recommendation—but an amendment specifically instructs insurers to disregard the Task Force's recommendations against routine mammography in women younger than 50.

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