Routine mammograms and the importance of rating preventive services

November 20, 2009, 1:17 pm

Mammogram new guidelines
This week’s news from the U.S. Preventive Services Task Force (USPSTF) on routine breast cancer screening has caused quite the stir. The USPSTF shared their new ratings of preventive services for breast cancer: Mammograms work really well in women in their 60s, pretty well in women in their 50s and not so well in their 40s. If you want to have mammograms in your 40s prepare for more confusing results including additional imaging to clarify and in some cases, a biopsy to be certain. And their recommendations included a couple of small but important points: breast self exam doesn’t lead to early detection of breast cancer nor do breast exams by doctors (remember we are only talking about women who have NO symptoms). The big news: Doctors and patients in their 40s should talk to each other about what to do rather than just do the same thing all the time out of pure routine. What’s wrong with that?

We seem to have developed the view that more prevention is always better, more testing is better than less, and that more information is always helpful. But this week’s news challenges that notion…and that is what it was meant to do. Making decisions is hard, especially when we have a health problem. But it’s also true when there are health issues we may not have yet. Surprise, life isn’t simple.

The focus in the media has been on the USPSTF recommendations without sufficient attention to some important context issues. These include:

1) Breast cancer (and for that matter almost all cancers) is not one disease. They afflict us in multiple forms each with a different natural history. Some breast cancers are very aggressive and respond slowly if at all to our treatment options. Others are slower growing and very responsive to treatment.

2) Mammography is a better test in some people and for some cancers than it is for others, especially when screening at an early stage is what we want from it.

3) The USPSTF focuses on recommendations for primary care doctors for patients with no symptoms getting routine care.

And the politicians on both sides should be ashamed of themselves for treating 16 volunteers from the private sector so shabbily. The USPSTF has been around for 25 years (some silver anniversary). It has always approached ratings of preventive services more rigorously than any public or private body. The task force is focused on recommendations for primary care not for specialists---they assume oncologists would not be seeing many completely healthy women who don’t have cancer. Several of them have spent their careers focused on prevention and have been recognized repeatedly for extraordinary performance. The rest are seasoned clinicians and successful researchers who are at the peak of their careers. The one thing you can be certain of is that each of them could make a lot more money spending their time on some other activity than this one.

So their timing wasn’t great. They meet three times a year and topics to address are planned months if not years in advance. The irony is that if they had paid attention to politics and delayed the mammography decision then we would have to be concerned about a political agenda. They are so independent they don’t think they need a political consultant or pollster --- they make their decisions based on science rather than opinion polls.

So let’s all pause and make sure we really want to vilify 16 scientists from the private sector who just provided prevention ratings for breast cancer preventive services based on the best science available. And the most controversial advice they provided was we should no longer use a cookbook approach to a serious problem but instead talk to our doctors about all the details, the pros and cons.

I think they all deserve one word……thanks.

John Santa, M.D., M.P.H., director, Consumer Reports Health Ratings Center

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