This week's hullabaloo about the latest recommendations for breast cancer screening from the USPSTF (U.S. Preventive Services Task Force) has been equally interesting and distressing for me.The recommendations can be found at http://www.ahrq.gov/clinic/USpstf/uspsbrca.htm and the three main points that have caused an uproar are:
(1) women without special risk are not advised to start screening for breast cancer before age 50,
(2) women between 50 and 75 years old can screen with mammogram every two years, and
(3) doctors should not teach breast self-examination (BSE).
I wish to use this opportunity to explain a few important concepts in health care as well as offer my professional perspective about the recommendations and the Task Force itself.
I will post a series of pieces over the next few days related to these subjects. Please follow along. I hope this is enlightening and interesting, and I look forward to feedback about the series and comments related to the topic.
These blogposts will cover a few issues, including:
- My thoughts on the USPSTF,
- Discussion of cancer screening and early detection,
- The breast cancer screening recommendations themselves, and
- Relating the new recommendations with three phrases I use regularly with my patients:
- "We have not yet caught up with Mother Nature."
- "Everything we do has risks."
- "Every test tells us something. But no test tells us everything."
First, regarding the USPSTF, I have been startled by some of the comments in the media suggesting the Task Force's recommendations are politically-motivated, based on cost-savings or misogynistic.
Frankly, the USPSTF is, without a doubt, my favorite source for recommendations about preventive services I should be discussing with and offering my patients. Why? Because it has consistently been objective in its analysis and clear in explaining how strongly the research supports recommendations. Perhaps more importantly, the Task Force is a neutral party and regularly reviews and updates its recommendations as new research is published and expert opinion changes.
Please see the USPSTF website at http://www.ahrq.gov/clinic/uspstfab.htm and note that the Task Force is assigned the task of conducting "scientific evidence reviews of a broad array of clinical preventive services, develop recommendations for the health care community, and provide ongoing administrative, research, technical, and dissemination support" and has been doing that since 1989 and the first publication of The Guide to Clinical Preventive Services.
That first Guide to Clinical Preventive Services had a massive influence on how I think about health care and practice medicine. I found that Guide one night at my medical school library. Taking a study break, I was stretching my legs and perusing the reference texts on the first floor. Standing there, likely with my mouth gaping as I read the analysis of the research and the recommendations on a great variety of health services, I had a semi-epiphany about health care and my first taste of "evidence-based medicine," the use of objective assessment of treatments and practices to help decide the best ways to work and where to focus our energies.
Since that first Guide to Clinical Preventive Services there was a second, in 1996, and for about the last ten years the Task Force recommendations have been available on-line with review and updates every few years and new topics/issues being added from time to time.
The USPSTF makes recommendations about many health issues which cover a good part of primary care medicine. Understand that trying to review all salient research and claims about health issues and preventive medicine is impossible for a single person, especially a medical provider spending the day seeing patients. The USPSTF judges the quality of research and explains well the practical lessons for the actual practice of medicine. Topics are broad, and include whether to screen for cancers; counsel about exercise; suggest patients take aspirin to prevent health problems; screen for anemia, family violence, depression, dementia, childhood thyroid disease, and countless other conditions.
The members of the Task Force are not political appointees. It was established in a way so it was somewhat guarded from politics and is within the Department of Health and Human Services (HHS), and they do not have any direct control of policies. They only comment on the strength of research for health care matters. According the website:
The USPSTF comprises primary care clinicians (e.g., internists, pediatricians, family physicians, gynecologists/obstetricians, and nurses). Individual members' interests include: decision modeling and evaluation; effectiveness in clinical preventive medicine; clinical epidemiology; the prevention of high-risk behaviors in adolescents; geriatrics; and the prevention of disability in the elderly. Current members of the Task Force ... have recognized expertise in prevention, evidence-based medicine, and primary care.
I am not surprised that politics has been thrown into the mix for the discussion about the new recommendations because of the current national debate on health insurance reform. That is typical, though regrettable, and the Task Force has been charged with playing politics in the past with some recommendations. But, in time, their recommendations more often than not do hold water, and other groups often move toward them as research and patient well-being is considered. In total, I would say it is obvious the Task Force does not include politics in making its decisions. I would say, however, that I am surprised at the Task Force members' public relations naivete as they reportedly did not anticipate the hub-bub about the breast cancer screening recommendation change and how the timing was less-than-optimal as has been reported http://www.nytimes.com/2009/11/20/health/20prevent.html?hpw
Suggestions that the Task Force's recommendations are part of on-going disregard for women's health issues sadden me. The USPSTF makes recommendations on a large number of services, all of which can be found at http://www.ahrq.gov/clinic/uspstf/uspstopics.htm and among those is the recommendation that doctors not screen for testicular cancer in asymptomatic men http://www.ahrq.gov/clinic/uspstf/uspstest.htm and a statement that the evidence is inadequate to assess the possible risks and benefits of screening men under age 75 for prostate cancer http://www.ahrq.gov/clinic/USpstf/uspsprca.htm. Those two male-health conditions kill about the same number of people each year as breast cancer. Just like the breast cancer screening recommendations, the statements are about the quality of the tests we have available and whether the research is showing them to adequately save lives and not cause excessive harm to patients, and are not commentary on the importance of the health problems themselves.
The Task Force currently has seven women (out of seventeen members), including the vice-chair who led the revision of the breast cancer screening recommendations. To claim they are anti-women's health borders on slander. In truth, over the years, the Task Force recommendations have been a powerful help in guaranteeing general support and insurance coverage for appropriate care and services while helping health care limit potential harm to patients with testing. I consider the Task Force not only not misogynistic, but also one of the best supporters of all patients' well-being.
My next blog post will consider two related topics: what does "screening" mean and what is early detection for cancer. I think patients, and society as a whole, need to understand those issues better than they might at this point. After that I will take a closer look at the actual breast cancer recommendations.
Please follow along. Any thoughts or feedback, if offered civilly, are appreciated.
-- Timothy Malia, MD
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