The fallout from Monday’s news that mammograms are being recommended less often for women continues to spread far and wide. Reactions have spanned the gamut: confusion, suspicion about the motives behind the new recommended guidelines, and even outright anger.
To summarize, here’s the exact wording of the U.S. Preventive Services Task Force’s new guidelines:
The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.
The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
The panel gives a "C" recommendation to mammography for women in their 40s, meaning that while there may be some benefit to individual patients, there is "at least a moderate certainty that the net benefit is small. Every-other-year mammograms for women ages 50 to 74 received a "B" recommendation, defined as "high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial."
Needless to say, this flies in the face of the messages women have been hearing for the past umpteen years about screening for breast cancer. The debate has been raging fast and furious, including right here on the West Central Tribune’s Web site.
"Better a false positive than a missed positive!" was one person’s opinion. Commenters called the recommendation "ludicrous" and "hogwash."
If there was ever any doubt that the public was paying heed to being screened for cancer, look no further. They’ve clearly gotten the message. There’s just one problem: The thinking behind the USPSTF’s new recommendations is more nuanced and less cut-and-dried than many people seem to believe.
First, this change is not all that new. There has been a back-and-forth debate for many years over the benefits of mammography screening for women in their 40s. The evidence that it’s clearly beneficial for the general population of women in this age group has never been particularly strong. This does not mean it’s worthless, especially when it comes to individual women and their own health history, circumstances and preferences. What it means is that the existing data don’t conclusively demonstrate that all women should be screened annually, starting at age 40, in order to improve the rate of early breast cancer diagnosis and decrease the number of deaths from breast cancer.
Second, no one is saying we should stop screening altogether or that we should withhold mammograms from women who really want them. The USPSTF’s own clinical summary for women in their 40s says it quite clearly: "Do not screen routinely. Individualize decision to begin biennial screening according to the patient’s context and values." (Emphasis added.)
I suspect what we’re seeing here is the beginning of a new overall approach to screening in general, one that is perhaps more balanced and more realistic about the relative harm vs. benefit than we’ve seen in the past. In fact, we saw hints of this last month already when the American Cancer Society stated the benefits of cancer screening have perhaps been overstated – then quickly backpedaled from its statement.
Experts in population health have long known there are limits to what screening can accomplish. This article, first published by Slate five years ago and reposted this week, demonstrates how this has been an ongoing debate:
Clearly, years of strong, scare-oriented public health messages, particularly with regard to breast cancer screening – "Don’t be a victim" and similar slogans – have gotten through to the public. The dogma that more is always better when it comes to cancer screening has taken hold, undiluted by any sense of screening’s drawbacks.
Yet there are drawbacks – ranging from the risk of false positives to the more complex issues of overdiagnosis and overtreatment. While early detection can certainly have benefits, it’s not true that screening can only help – and can’t hurt. Indeed, skeptics within the medical community, including the authors of the JAMA survey, have started to become more vocal in an effort to create a more balanced public view.
The operative words here are "public view." It has always been challenging for advocacy groups, such as the American Cancer Society, to educate a public that varies widely in its level of health literacy and receptiveness to the message. Simple messages – "get screened" – seem to work best but they unfortunately gloss over the complexities and tend to leave the public with information that’s incomplete or minus significant chunks of context. It’s no wonder, then, that people are confused and upset when they’re now hearing something that, to them, sounds different.
The New York Times talked this week to women and sifted through online comments, and found a fair amount of skepticism:
… Still there remains plain old confusion. Leslie Haltiner, a teacher’s aide in Denver, said she was uneasy with the idea of shifting her own approach to breast cancer detection based on new federal guidelines without first knowing the medical specifics behind them, and also what oncologists and breast cancer awareness groups were saying.
"Everything I’ve heard, from the health advertisements to the medical professionals, says that even if you don’t have a family history of breast cancer, it doesn’t mean you won’t get it," Ms. Haltiner said. "This sends a real confusing message. Wow, they’re doing a complete 180."
It’s also hard to take the emotion out of the issue. Almost everyone knows someone whose breast cancer was detected with mammography. Anecdotes can be so powerful that it’s easy to overlook the fact that the plural of "anecdote" is not "evidence."
What are we to make of a recommendation that comes from an organization described as a government panel? The U.S. Preventive Services Task Force falls under the umbrella of the Agency for Healthcare Research and Quality, itself an arm of the U.S. Department of Health and Human Services. The task force’s mandate is to "conduct 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."
Plenty of critics see the new mammography recommendation as a first step down the slippery slope of government-dictated rationing of care. Is this because the recommendation happens to come from a nonpartisan government panel (the members of whom, by the way, all work in the private sector)? It’s worth keeping in mind that organizations such as the American Cancer Society, which continues to call for annual mammograms for women in their 40s, are in the business of advocacy and will likely take a stance that’s consistent with this mission. It’s also worth pointing out that not all advocacy groups are in consensus on this issue; the National Breast Cancer Coalition backs the new USPSTF recommendations, as does the National Women’s Health Network.
As I read the news stories, the analyses and the online comments in reaction to these new evidence-based guidelines, the word that comes to mind most often is "disturbing." I’d like to think there is some support among American consumers for evidence-based medicine – that is, medical intervention that has been shown to be effective and to achieve the desired outcome, vs. simply offering intervention for the sake of offering something or because the patient wants it. I’d like to think we’re capable of considering the facts instead of reacting in emotional knee-jerk fashion.
Some commentators have already started to wonder whether the American public is truly on board with evidence-based care. Physician-blogger Dr. Kevin Pho thinks it may be a tougher sell than anyone realizes: "The thought that ‘more medicine is better testing’ is so pervasive in the mindset of the American public that it’s going to be extremely difficult to scale back testing in this country. Even if it’s the right thing to do." He followed up these thoughts with another post that explores what the backlash on breast cancer screening might mean for health care reform.
My guess is that most physicians, and most women, will probably stick with annual mammograms starting at age 40. Perhaps a minority of women will appreciate that they can skip the annual mammogram routine without being viewed as irresponsible or needlessly putting their health at risk. Maybe some day our thinking will shift more towards the evidence. But right now, I’m not sure physicians are ready to embrace the USPSTF’s new guidelines, and I don’t think the American public is ready for them either.
Update, Nov. 20: The New York Times analyzes how the debate over cancer screening has revealed a culture clash in medicine. The Everwell site takes a look at five of the top myths about breast cancer screening and the USPSTF’s recommendations. Gary Schwitzer, a blogger and journalism professor at the University of Minnesota, also provides a running commentary on how the mainstream media has been covering this issue.
West Central Tribune file photo by Bill Zimmer