HHS urged to pull controversial mammography advice

Radiologists back a lawmaker's demand that the department cease promoting recommendations issued last fall.

By Chris Silva — Posted May 31, 2010

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Lawmakers have directed the Obama administration to set aside revised breast cancer screening recommendations issued last November by the U.S. Preventive Services Task Force after the advice was met with strong criticism by some physicians and women's groups. However, the Dept. of Health and Human Services still lists the revised recommendations as the most current ones, and the lawmaker who authored the provision wants that changed.

On May 12, Sen. David Vitter (R, La.) sent a letter to HHS asking it to remove from its website and cease all promotion of the task force recommendations related to breast cancer screening and mammography. The task force guidelines, published in the Nov. 17, 2009, Annals of Internal Medicine, said women younger than age 50 do not need routine mammography screening and that women ages 50 to 74 should get a mammogram every two years. The guidelines also recommended against teaching women to do breast self-examination.

The revisions marked a shift from the task force's previous recommendations, issued in 2002, that called for a mammography every one to two years for all women older than 40. The task force later clarified that the decision to obtain the screening for a woman younger than age 50 should be an individual one that takes specific patient circumstances into account.

Vitter called the recommendations "ill-conceived" and said they were offered without transparency and input from those with experience and expertise in the field. He successfully amended the health system reform law to say that the November 2009 recommendations should not be considered the most current ones.

The Agency for Healthcare Research and Quality, the branch of HHS that lists the revised recommendations on its website, did not return calls requesting comment.

Physicians on both sides

Although many have distanced themselves from the revised mammography recommendations, not all physicians have given up on them.

Christine Laine, MD, MPH, an internist in the Philadelphia area, said the recommendations are a practical, effective reworking of outdated policies that make them more in line with how doctors practice globally. She had recommended annual mammograms for her patients ages 50 to 70 but has been following the revised guidelines since they were issued.

"I find it curious that [Vitter's] reasons for removal are that they were developed without transparency and expertise," Dr. Laine said. "When you compare the methodologies of the task force compared to some others, you see that they're clearly specified."

She noted that the disputed language is simply a set of recommendations that don't have to be followed to the letter for every patient. Because there's no evidence that screening women in their 40s decreases mortality rates, heeding the guidelines could avoid unnecessarily exposing women to the adverse effects of chemotherapy and surgery if excessive testing leads to more false positives, she said.

But the American College of Radiology applauded Vitter's letter. According to the college, the task force ignored direct scientific evidence from large clinical trials and based the recommendations on conflicting computer models and the concept that the parameters of mammography screening change abruptly at age 50.

"These recommendations ... have undoubtedly confused many women to the point that they have refused needed care," said James H. Thrall, MD, chair of the ACR's board of chancellors. "Breast cancer screening policy decisions based on faulty recommendations may result in the unnecessary loss of thousands of lives."

Dr. Thrall also noted that 2008 legislation gave HHS the authority to consider task force recommendations in making Medicare coverage determinations. "Allowing a small group of people, who may or may not have an expertise in the field on which they are making recommendations ... and have those serve as health coverage policy is unacceptable and potentially dangerous," he said.

The American College of Obstetricians and Gynecologists and the American Cancer Society are among the groups that said they would continue to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40.

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The disputed guidelines

In November 2009, the U.S. Preventive Services Task Force updated its breast cancer screening guidelines for the first time in seven years, a move that proved controversial. The task force:

  • Recommends biennial screening mammography for women ages 50 to 74 years.
  • States that the decision to start regular, biennial screening mammography before age 50 should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
  • Concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 or older.
  • Recommends against teaching breast self-examination.
  • Concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women 40 or older.
  • Concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities for breast cancer.

Source: U.S. Preventive Services Task Force breast cancer screening recommendations, updated December 2009 (link)

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