Last November, we received new guidelines for mammograms from a governmental organization called the United States Preventative Services Task Force (USPSTF), recommending that mammograms should be given to women at age 50 rather than age 40 and every other year rather than annually. The announcement elicited an outcry from almost every organization around the country because early detection is key to saving women’s lives from breast cancer.
At last, organizations are finally beginning to fight back and buck the USPSTF recommendations. In early January, the American College of Radiology and the Society of Breast Imaging published their guidelines recommending mammograms at age forty for average risk women and at age 30 for those at higher risk. “The significant decrease in breast cancer mortality, which amounts to nearly 30 percent since 1990, is a major medical success and is due largely to earlier detection of breast cancer through 
mammography screening,” Dr. Carol Lee Of Memorial Sloan-Kettering Cancer Center in New York said in a statement.
The recommendations from USPSTF came as no surprise, as the organization has already undermined screening guidelines for other cancers leading to death.
For example, last spring the American Urological Association revised guidelines for prostate cancer screening and strongly recommended beginning screenings at age 40 rather than waiting to 50. This announcement was the organization’s nimble response to the USPSTF’s statement that there is “insufficient evidence to recommend screening men for prostate cancer.”
Guidelines from USPSTF for colon cancer screening have become increasingly vague, recommending less thorough –– and less expensive –– screenings in place of colonoscopies. USPSTF also changed the interval between colonoscopies from five years to ten years. I am currently treating two patients who attempted to wait that long between colonoscopies only to come down with metastic colon cancer before the ten years was reached. The USPSTF guidelines are also somewhat at odds with the American Society of Gastroenterology’s recommendations for screening colonoscopy at age 50 and at age 45 for African-Americans and even earlier for any patients who might be at risk. This is a dilution in what should be done for colon cancer screening because many fools will believe it.
Then there are the cancers that the USPSTF completely ignores. I can understand not recommending screening for pancreatic cancer; screenings do not help with that disease. But for lung cancer, the most deadly form of cancer in both men and women, and ovarian cancer in women, the USPSTF offers no screening recommendations, and that completely baffles me. Lung cancer can easily be detected early with simple chest x-rays, and ovarian cancer with a transvaginal ultrasound. And with all cancers, early detection is key to successfully treating the diseases.
The USPSTF often offers the rationale that by conducting screenings, we are needlessly scaring people. True, screenings sometimes show what we call false positives that can lead to an additional expense for biopsies, that may actually show that no cancer is present. But what the task force doesn’t come out and say is that their primary focus is to save money. Forget saving lives –– it’s cheaper to let you die.
Why, you might ask, does this group have such power over the way we practice medicine?
In 1984, the Department of Health and Human Services formed the U.S. Preventive Services Task Force as an independent panel of experts in primary care and prevention that reviews the effectiveness of clinical preventive services and develops recommendations. Looking at evidence from clinical trials, the task force evaluates the costs and benefits of screenings, then assigns a recommendation for or against each particular screening.
What most doctors and their patients don’t realize is that there is a significant gap between the USPSTF guidelines and the statistics for actual outcomes in individual patients. Because of the length for each study –– in some cases, years –– by the time the USPSTF issues guidelines, the research and statistical information can be outdated.
Another major problem is that the standards of the task force are so strict, that the USPSTF contends that many screenings are not sufficiently supported by evidence. This doesn’t mean the screenings aren’t useful for many people; it just means that the Task Force did not find evidence that the benefits of those screenings clearly outweighed the risks. If the research is deemed insufficient or insignificant, no recommendations may be issued at all. The USPSTF is so out of touch that they do not recommend that women perform self-breast exams or boys perform self-testicular exams, not to mention that they don’t endorse skin exams, checking blood sugars in pregnant women, screening for lung and ovarian cancers, and –– perhaps most ridiculous of all–– routine physicals.
Let’s look more closely at breast cancer as an example, since that’s been in the news. Death rates from this disease have declined 2.3 percent since 1990, a drop that can be attributed to earlier detection through self-exams; earlier and more aggressive screenings of women with a family history of breast cancer; better imaging techniques such as digital mammography, ultrasound, and breast MRI; and improvements in treatments like chemotherapy, radiation therapy, and surgery. Instead of encouraging earlier detection, however, the USPSTF states that for women ages 40 to 49, “the evidence that screening mammography reduces mortality from breast cancer is weaker and the absolute benefit of mammography is smaller than it is for older women” and recommends mammograms every other year rather than every year.
What kind of sense does that make? If a woman in her forties has a clear mammogram in the morning but cancer starts growing by the time she goes to bed that night, what then? She will be dead before her next mammogram! The only reason we do a mammogram in the first place is to discover a cancer as early as possible. Why would we not continue to do that routinely? After all, breast cancer is still the number two cause of cancer-related deaths in women.
The USPSTF guidelines actually cite the potential for false positives as a valid reason for reducing screening for breast cancer, claiming that the mammograms can “create unnecessary anxiety, biopsies, and costs.” (See my earlier post about false positives and negatives here.) It even goes on to say that there’s poor evidence to support the efficacy of self-breast exams in reducing mortality –– and goes so far as to say that it recommends against teaching self-exams! However, from what I’ve seen in my practice, most survivors of breast cancer found their own tumors. The only thing that is better is to find the tumor before a woman can detect it by feel, and the only way to do that is through mammography or ultrasonograms.
You can read more about what USPSTF does not recommend here.
Another thing we should be aware of is that the USPSTF doesn’t just issue guidelines. The task force also determines what services are covered by Medicare and Medicaid. In turn, insurance companies base their coverage benchmarks on Medicare guidelines. USPSTF is in a position to significantly influence what will be covered in the new health-care plan being hammered out in Congress.
Guidelines from the USPSTF might save billions, but where does that leave us, the patients? If we and our physicians go strictly by the USPSTF guidelines, many of us will seek medical care only when we have developed symptoms, and by that time, whatever disease we have may be too advanced to prevent it. Early detection is key to intercepting or even preventing a statistically predictable and often preventable illness.
The real tragedy is that the cost for this fiasco will ultimately be shifted to taxpayers. This is rolling back health care to the 1950s, ignoring all the advances we have made that should allow us to live better longer. This is disease management, not health maintenance. It doesn’t take a rocket scientist to figure out that health statistics will soon start rolling back as well. This is even more scary to me, as both a doctor and a human being.
Thanks again for addressing this issue. It’s interesting to me that the “P” in the acronym stands for Preventive. I’ve never thought a “normal” mammogram screening was a waste of my time or money. I guess the success of the campaign for practicing preventive medicine is beginning to hurt our poor insurance companies.
I share your concern for beleaguered insurance industry, poor things. If we had real preventive screening we would have prevented them a long, long time ago!