Mammogram Advice Based On Science

December 04, 2009|By Miriam Alexander

We at the American College of Preventive Medicine support the updated United States Preventive Services Task Force recommendations on breast cancer screening. On Nov. 17, the task force released recommendations that women age 50 and older should have screening mammography every two years, and women in their 40s should decide whether to have screening mammography on an individual basis after talking with their doctors. Since then, misinformation and conspiratorial rumors have been rampant, including allegations that the task force is a mechanism for government or insurance industry cost-cutting at the expense of women's health.

Much of the response by media, pundits and policymakers is a result of two converging factors. The first is a lack of understanding about how the task force operates and how to interpret its findings. The second is a politically charged environment generated by the health care reform debates.

Let's set the record straight: The task force is not a government body. It is an independent panel of health care professionals, mostly primary care physicians - pediatricians, family physicians, internists, obstetricians and gynecologists - many of whom teach at prestigious academic medical centers. To characterize the task force as a collection of stooges for the insurance industry is simply disingenuous. In fact, the task force does not consider cost as a factor in making its recommendations. It conducts rigorous evaluations of the evidence to provide primary care clinicians with evidence-based guidance on using patient-directed clinical preventive services.

The task force concerns itself with clinical services aimed at patients who are healthy or do not have symptoms; it therefore deals with screening to detect early disease in which treatment or intervention will make a difference in ultimate health outcomes. The recommendations are not intended for people who are already ill or have symptoms. We agree with the task force that the tolerance for risk vs. the benefit of any service delivered in an asymptomatic population is different than in individuals who may already be ill.

Any competent doctor will tell you how important it is to consider both the benefits and the drawbacks of any treatment or screening service that they offer. The task force, using rigorous methodologies, examines the scientific evidence for preventive services. It carefully weighs the benefits and the drawbacks before making its recommendations - based on what's best for whole populations, not each individual.

Ideal preventive care for healthy individuals should "do no harm," as is stated in the Hippocratic Oath. Mammography may lead to harms such as false positives and subsequent unnecessary tests and biopsies. Furthermore, though unquestionably able to pick up true disease that needs treating, mammography also detects certain breast cancers will never spread and will never cause signs or symptoms. Our challenge in the medical community is that at the time of diagnosis, we do not know which cancers will lie dormant or regress and which will go on to cause significant suffering. We therefore move forward on treating essentially all cancers detected. A recent study suggests that 1 in 3 breast cancers detected on screening results in unnecessary surgery, chemotherapy and/or radiation therapy.

This recommendation also has nothing to do with health care reform. The task force voted on this recommendation more than a year ago - before the current administration took office and before health reform became a centerpiece of public policy. This recommendation is not about rationing, health care costs or politics. It is all about making intelligent decisions from a scientific perspective as to what works and what does not, and weighing medical benefits against negative outcomes.

As preventive medicine physicians, we support the value of mammograms for early detection of breast cancer. We know mammography screening saves lives. But it is important for women to be informed about the risks and benefits and make their decision in conjunction with their doctors. Let's not politicize this issue and these recommendations. Too many lives are at stake.

Dr. Miriam Alexander is president-elect of the American College of Preventive Medicine. She is on the faculty at the Johns Hopkins Bloomberg School of Public Health and is director of the school's General Preventive Residency Program. Her e-mail is mhalexan@jhsph.edu.

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