USPSTF: Rationing or Rational Use of Screening Tools for Detecting Breast Cancer

Yesterday, the US Guide to Preventive Services released the latest guidelines on breast cancer screening recommendations. The press went wild and said this was government rationing of preventive testing. The "US Guide to Preventive Services Task Force Guidelines show stark differences of opinion with the specialty groups regarding screening, diagnostic and treatment methods. When the numbers came in, physicians following specialty colleges' recommendations were overtesting, overtreating and unnecessarily worrying patients. The research did not back up the specialty standards." Most of these recommendations are by convention rather than by scientific medical evidence.


Let's set the record straight - The USPSTF never recommended routine screening at 40 - there was insufficient evidence to recommend for or against routine mammography or clinical breast exams in the 40-49 y.o. age group for the general population - NOTHING CHANGED. It was the specialty & disease societies such as American Cancer Society, AMA and American College of Obstetrics and Gynecology that made these recommendations. Other groups, such as the American College of Physicians, said it should be based on the risk of the individual patient. It should always be based on the individual patient's need - these are population guidelines - of course, the patient in front of you may have different needs.

What did change? The 2002 Guidelines said mammography every 1-2 years was recommended for women age 50-69y.o., although recommendations for high risk women 40-49 and healthy women > or = 70 may be made on other grounds. Today's Guidelines say: Mammography screening is recommended every 2 years for women age 50-74. The USGPSTF is recommending screening for a LONGER period of time, NOT less.

Why every two years screening? Because mammograms are not benign - they expose a patient to radiation. The USPSTF also says "Although false-positive test results, overdiagnosis, and unnecessary earlier treatment are problems for all age groups, false-positive results are more common for women aged 40 to 49 years, whereas overdiagnosis is a greater concern for women in the older age groups." Subsequent biopsies will change the breast architecture and make it more difficult to interpret future exams. Evidence also shows that the more mammograms a woman has the more likely she will have a "false-positive" mammogram. According to a Harvard Pilgrim Healthcare study in the Journal of the National Cancer Institute which followed women over a 10-year period with "9747 screening mammograms, 6. 5% were false-positive; 23.8% of women experienced at least one false-positive result. After nine mammograms, the risk of a false-positive mammogram was 43.1%." Clearly more diagnostic testing does NOT equate to higher quality medical care.

Who is the US Preventive Services Task Force?

The past 24 hours I have heard at least a dozen media pundits commenting on when breast cancer screening should or shouldn’t be done. Apparently most seem to think that disease and specialty societies trump the US PSTF. They have bashed “government bureaucrats” who are apparently trying “to deny women care.”

Let’s understand the nature of this Task Force – It is lead by the Agency for Healthcare Research and Quality (AHRQ). All members reviewing breast cancer screeening, save the two PhD nurses, are physician experts, from various specialty colleges, academia and public health service; the majority also have public health degrees in addition. “Federal partners include the Centers for Disease Control and Prevention (CDC), Department of Defense (DOD), Centers for Medicare and Medicaid Services (CMS), Department of Veterans Affairs (VA), Health Resources and Services Administration (HRSA), National Institutes of Health (NIH), U.S. Army Center for Health Promotion and Preventive Medicine, and the U.S. Food and Drug Administration (FDA). Primary care partners include the American Academy of Family Physicians, American Academy of Pediatrics, American Academy of Physician Assistants, American College of Obstetricians and Gynecologists, American College of Physicians, American College of Preventive Medicine, America's Health Insurance Plans, the Canadian Task Force on Preventive Health Care, the National Committee for Quality Assurance, and the Pan American Health Organization.” [1]

“The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the "gold standard" for clinical preventive services. [Here are the methods.] The mission of the USPSTF is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care. Recommendations issued by the USPSTF are intended for use in the primary care setting… to present health care providers with…the evidence behind each recommendation, allowing clinicians to make informed decisions about implementation.” [2]

No other organization goes through such a rigorous examination of the evidence for clinical recommendations for the asymptomatic general population. These recommendations are obviously different than for a patient who is symptomatic, has a family history or would otherwise be considered high risk. It is also important to understand and weigh the capabilities, limitations, benefits and potential harms of a given screening test. The distinction not being made by the press is the difference between population medicine versus care of the individual patient.