Some may read this post and tell me that I don’t know what I’m talking about. Granted, I’m not an oncologist. Hell, I’m not even a doctor. Come to think about it, I don’t even have a Master’s degree. However, I do have a background in business and can presume that we haven’t begun to see the true outcome of the new breast cancer screening guidelines released earlier this week.
Cancer is something that is very close to me (as it probably is close to a lot of the people who will read this). I’ve lost family members to cancer and have friends that are battling it in one form or the other. For this reason, I decided to learn more about the recommendations published by the panel, do some research on the panel itself and similar panels around the world, and what the experts; American Cancer Society (ACS), American College of Obstetricians and Gynecologists (ACOG), and the American Society of Clinical Oncology (ASCO) think of them. As I was doing this research, I also found that congress has four bills in the works that discuss breast cancer screening and treatment.
So, let’s begin. The guidelines released on the 16th are radically different from all previous guidelines published by the same U.S. Preventative Services Task Force (USPSTF). As recently as March 2009, “The U.S. Preventative Services Task Force recommends screening mammography, with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and over.” (http://www.ahrq.gov/clinic/pocketgd09/gcp09s2.htm#BreastScreening).
The USPSTF guidelines released Monday: (http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm)
- 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 recommends against teaching breast self-examination (BSE).
The USPSTF states:
“The harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results. Furthermore, one must also consider the harms associated with treatment of cancer that would not become clinically apparent during a woman's lifetime (overdiagnosis), as well as the harms of unnecessary earlier treatment of breast cancer that would have become clinically apparent but would not have shortened a woman's life. Radiation exposure (from radiologic tests), although a minor concern, is also a consideration.”
It just doesn’t sit right with me that one of the reasons to not screen is because of the “inconvenience due to a false-positive”. I understand that it is truly horrific to be diagnosed with cancer. Personally, I’d rather be falsely diagnosed initially rather than not being diagnosed at all. Maybe it’s just me, I don’t know. I’m just thinking of the woman who is much younger than 50 who may not be diagnosed until either the cancer has metastasized and is too late or 50 years old.
One of the reasons why the U.S. is a world leader in cancer treatment is because of the noble work done is cancer research facilities across our great country. We’re lucky to have the Dana-Farber Cancer Institute in our own back yard. The American Cancer Society rejects the USPSTF recommendations. In a 11/17/09 press release: (http://www.cancer.org/docroot/MED/content/MED_2_1x_American_Cancer_Society_Responds_to_Changes_to_USPSTF_Mammography_Guidelines.asp?sitearea=MED)
The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. When recommendations are based on judgments about the balance of risks and benefits, reasonable experts can look at the same data and reach different conclusions.
The ACOG has not adopted the guidelines and also alludes to a future potential problem (more on that later): http://www.acog.org/from_home/Misc/uspstfResponse.cfm
The College continues to recommend that Fellows advise mammography screening for their patients aged 40 and older and that they counsel their patients that BSE has the potential to detect palpable breast cancer and can be performed. Fellows should be aware that the new USPSTF recommendation against routine screening mammography for women aged 40-49 (a grade C recommendation) has implications for insurance coverage, as some insurers will cover only preventive services rated as an "A" or a "B" by the USPSTF. Fellows should counsel their patients that insurance coverage for "routine screening" mammography may become variable and that patients should address this question with their insurers. These recommendations do not apply to high-risk women or patients with clinical findings, and they should be managed accordingly.
Congress has three bills; HR995, HR1691, HR1740, and HR2279 (http://thomas.loc.gov ) that discuss breast cancer in them. Among other issues addressed, the bills require insurance companies to extend the coverage for annual mammograms to women 40 years and older. They also have a campaign to make young women aware that they are also at risk.
Here is where I’m going to lose people…The same USPSTF that published these guidelines is the same task force referenced in the House’s healthcare bill. So, it wouldn’t be a stretch to assume that despite the other bills that will probably die in congress, HR3962’s provision will set which services the government will pay for. It could also be the guideline for what insurance companies will use to set their coverage plans. If you don’t believe me, here is the whole 1,990 page bill. Please go to pages 106-107. http://docs.house.gov/rules/health/111_ahcaa.pdf
The reason why the U.S. is a leader in cancer research is because, until now, we did not have a government panel with the strength the USPSTF will have if/when the Healthcare bill is passed. I keep hearing that we need to be like the rest of the world in health care. I keep hearing about England and other countries in Europe that have some form of socialized healthcare. Then why don’t we travel to London or Paris for treatment instead of people coming to our city (and country) from across the globe? The U.S. cancer survival rates far surpass those in European countries. The same countries that rely on the same panels/task forces to create clinical guidelines for screening and treatment. Patients with breast cancer, for example, have a much lower survival rate after 5-years (79% vs. 90.1%). Prostate cancer survival rates after 5-years is 77.5% vs. 99.3%. The reason “probably represents differences in timeliness of diagnosis.” Again, if you don’t believe me check this website. I’m not just making this up. http://www.medscape.com/viewarticle/561737
This issue is too important to politicize. This really isn’t meant to be political. Honestly! It’s just something that doesn’t sit right with me.
In closing, again I am not a doctor and would welcome comments from the medical professionals that may read this.
If you would like to donate to organizations dedicated to finding treatments and cures for cancer, please follow the links below. Thanks.
http://www.nationalbreastcancer.org/How-To-Help/Donate-Online.aspx
