Blog | Thursday, November 19, 2009

Rethink pink: breast cancer screening evidence met politics and lost


The controversy started at exactly 5 p.m. Monday, when the Annals of Internal Medicine lifted its embargo on new breast cancer screening recommendations and the rest of the medical community simultaneously released opposing positions. With lines drawn and positions taken, a furor began ultimately pitted evidence-based medicine against political machinations. So far, medicine has lost.

Shown is a mammogram of a fatty breast with an obvious cancer, indicated by an arrow. Photo by Dr. Dwight Kaufman. National Cancer InstituteThe recommendations, issued by the U.S. Preventive Services Task Force, suggest that asymptomatic individuals with no family history or other risk factors could wait before starting mammograms and undergo screening every two years instead of annually. They balanced the benefits of less frequent screening against the harms of more frequent screening by reviewing the evidence and creating models.

The recommendations have since been on the pages of every newspaper in America, from the smallest locals to the biggest dailies. The American College of Physicians is tracking "impressions," as they're called, in the millions.

There's always a downside to new knowledge, and it's playing out in week following the announcement. It will take time for physicians to digest the new recommendations. It will take time to explain them to patients. In the meantime, public discourse has been messy.

Experts have told women to talk to their doctors about how evidence-based recommendations apply to individual circumstances. But other medical societies are sticking to their guns on annual screenings at earlier ages, and it's unsettling for patients to see doctors disagree and even more unsettling when shouting matches erupt on television.

But neither the government nor insurers are rushing out to make dramatic changes to existing practice of medicine. To calm fears, HHS Secretary Kathleen Sebelius clarified that the doctors who drafted the recommendations, the U.S. Preventive Services Task Force, comprise an independent body of experts who review evidence but don't set policy. To calm fears, she stated that women should still go to their doctors to discuss their individual needs. Insurers aren't going to change their policies, either.

In short, the recommendations inform the talks between doctors and patients. They give physicians something to consider during the informed consent process. Consider the words of family physician David Baron, MD, who said, "I respect [USPSTF] a great deal. They've got no horse in the race. They are independent experts." Take it from practicing physician Jan Gurley, MD, who summarized in plain language how recommendations should impact encounters between physicians and patients.

This is in contrast to internist and TV commentator Elizabeth Lee Vliet, MD, who went on the attack about a "distant and impersonal 'review of data' from published studies." In an op-ed shopped around to media outlets, she further ranted that, "I am profoundly concerned that government 'experts,' far removed from the daily care of patients, are sitting 'on high' to proclaim that women don't need to start mammograms at age 40."

And of course, Dr. Vliet decried it as a cost cutting measure and as the start of "government-mandated, guideline-based rationing of health care." Those are her poorly chosen words. But she's not alone.

U.S. Rep. Marsha Blackburn of Tennessee bemoaned that, "This is where you start getting a bureaucrat between you and your physician." Rep. Michele Bachmann of Minnesota joined the misinformation brigade, starting her press conference on the task force recommendations by blaming President Obama and Speaker of the House Nancy Pelosi. Watch for yourself.

Hijacking evidence-based recommendations to further partisan debate is a semantic trick. And it's a disgrace.