"I want to work with the AMA so we can scale back the excessive defensive medicine that reinforces our current system, and shift to a system where we are providing better care, simply - rather than simply more treatment."
-President Barack Obama, in a speech to the AMA June 15, 2009-

It is often said that words have consequences, all the more so when the speaker is the President of the United States. It was announced this week that the US Preventive Services Task Force has recommended against the annual breast cancer screening for women over 40 that has been the standard of care since 2002. The USPSTF also recommends against mammograms for women 75 years and older. It further recommends against the teaching and practice of self-examination. Analysis on the recommendations is provided by Medscape, a physician's resource service. Link at:
http://www.medscape.com/viewarticle/712473

The basis for this decision was a "lack of evidence" showing any considerable benefit from routine screening of women under 50 years of age. They cited a National Cancer Institute study that found out of every 1000 women screened under age 40, only 7 deaths would be prevented, while 470 would receive false positives, causing anxiety and unnecessary retesting The deaths seem statistically insignificant until the many thousands of women who undergo annual breast screening through mammography are factored in. The 7 deaths prevented per 1000 mammographies needs to be looked at under the umbrella of the total number of women saved. Far more than 1000 women have routine mammograms. For arguments sake let's say that 500,000 women undergo the procedure (an extremely conservative estimate). That would be 500 (the thousands) times 7 (women saved per 1000 under 50 years of age) giving a total of 3,500 women who were saved an untimely death in the prime of life. The argument for not performing the procedure is a dodge. The anxiety caused by a false positive will be met with great joy when the retest comes back negative. The woman who dies because no one thought routine screening was necessary has no such happy result.

In a contrast to the USPSTF recommendations, a report by Memorial Sloan-Kettering Cancer Center (http://www.mskcc.org/mskcc/html/65280.cfm) issued in November of 2007 rolls out the following data. A projected 184,450 new cases of breast cancer were expected to be diagnosed in the US in 2008. The actual number was closer to 211,000. Of those cases, 41,000 would die from the disease.Their study states that regular screening of women with no symptoms has reduced breast cancer deaths by 45%.

The USPSTF makes no allowance for Ultrasound or MRI technology, again claiming insufficient data to recommend these procedures. Sloan-Kettering does advise these methods in their report, while expressing a preference for mammography. Both Ultrasound and MRI are far more expensive, and the results are not as proven as a standard mammogram. Ultrasound is a subjective assessment based on the skill level of the ultrasound technician. MRI does detect tumors as well as mammography, but is a more invasive procedure requiring injection of contrasting dyes.

This makes the basis for the USPSTF recommendations purely economic. Less mammograms equals less money spent. The only upside for the patient is that women receiving false positives won't have to go through "anxiety" and more expensive testing to find out that they have no cancer. The thousands of women under 40 who are saved every year by early detection are dismissed as an insignificant statistic. That statistic could be your wife, your sister, your mother or your daughter.

The recommendations of the USPSTF come under further question when looking at the makeup of the panel (http://www.ahrq.gov/clinic/USpstfab.html#members). Of the 16 members, 13 are medical doctors, 2 hold Ph.D's in Nursing, 1 holds a Ph.D in Public Health. Most members are hospital and public health administrators. Only one member specializes in women's health issues. There is not an oncologist on the panel.

This panel, USPSTF, meets to advise The US Department of Health and Human Services on best medical practices. The mission statement of the panel is as follows - "The mission of the USPSTF is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care". In short, they advise as to whether there is a sufficient benefit to society at large to endorse any specific medical treatment. If there is no benefit to society at large, they recommend against having the procedure as a routine medical practice. Though it is not mandatory for these recommendations to be put in place, they generally are. Once in place, incentives are part of the Medicare and Medicaid payment protocols which means that "best practices" are paid out with the least headache to medical providers. Going against medical "best practices" opens up a mountainous volume of paperwork, eating up staff hours and time that the medical provider can better spend on patient care. The financial pressure placed on providers forces many of them to just go along with the recommendations. The annual mammogram for breast cancer screening in women over 40 is not recommended by this panel. An exam every two years is recommended for women from 50 to 74 years of age. There is no recommendation for any breast cancer screening in women 75 and older. No other safe and effective preventative course is recommended to take the place of annual breast screening using mammograms. (http://www.ahrq.gov/clinic/USpstfab.html#members)

Many conservatives and some liberals were considered being alarmist with regard to the government advising the medical community on what should be routine medical practice. The term "death panel" was tossed around as a buzzword with no meaning attached to it. President Obama has said that "No one will pull the plug on Grandma". However, we have here a government panel advising the medical community against continuing a practice that has proven to save lives in numbers that may not be statistically significant, but those lives are very significant to the people saved and to their families. Should the annual mammogram be discontinued as routine practice, the USPSTF will indeed be a death panel for several thousand women every year. Common Sense dictates that this recommendation not be followed, and extreme care should be taken in any government involvement in individual health decisions.

RLB