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BMJ, December 5, 2009

Mammograms, poor communication, and politics

What lessons can be learned from the furor over new breast screening recommendations?

The US Preventive Services Task Force, though appointed and staffed by the government, is an independent, rotating panel of doctors, nurses, and methodologists. Its mission since 1984 has been to systematically review the evidence on clinical preventive services—screening tests, chemoprevention agents, and counseling interventions—and to publish recommendations based on their findings. (Full disclosure: I formerly directed the task force staff and edited its first book in 1989.)

The task force is no stranger to controversy. In order to recommend a given preventive service, its methodology requires good evidence that the benefits exceed the harms. Many of the panel’s early recommendations, when systematic reviews and evidence-based recommendations were not widespread, differed from those of established authorities. Disease-specific advocacy groups and medical specialty societies were often furious when the task force did not agree with them about the effectiveness of various screening tests for colorectal, prostate, skin, or breast cancer or for lead poisoning or coronary artery disease.

Relations between the task force and other groups have generally been better since the late 1990s, because evidence-based methods have become mainstream, and in some cases (such as for colorectal cancer) new trials have been published that allowed the task force to broaden its recommendations. Also, the task force became better known in the United States and more prestigious. It was officially authorized by Congress and its recommendations were cited in legislation concerning the Medicare program and preventive services. Current health reform proposals refer to services recommended by the task force in mandating appropriate preventive care. As a result of these trends, recommendations of specialty societies, advocacy groups, and the task force have in many cases become similar, if not identical.

Breast cancer screening seemed to be an example of this trend when, in 2002, the task force changed its longstanding neutral (“C”) ranking of mammography for women in their 40s to a positive one, recommending screening every 1 to 2 years for women aged 40 or older. This was similar to recommendations from groups such as the American Cancer Society and the American College of Obstetricians and Gynecologists.

So it should have been no surprise that, when the task force seemingly reversed its 2002 position on November 17 this year, recommending against routine screening of women in their 40s, it would make headlines. In fact it unleashed a firestorm. The story made the front pages of national newspapers daily for most of the week. The recommendations were widely and loudly denounced by radiologists, breast cancer survivors, media doctors, gynecologists, and politicians. Medical experts called the task force “idiots,” and conservatives lined up to denounce the report as an Obama administration plot foreshadowing what would happen under health reform.

What in the world happened? Almost no one disagrees about the evidence. Screening mammography can save women’s lives if it is started in their 40s, but it is much more accurate in older than younger women. The task force reviewed the number needed to screen to prevent one breast cancer death, which is around 1,900 women in their 40s versus 377 women in their 60s. It looked at six new modeling studies, which found that an average of 80 percent of the effectiveness of breast cancer screening could be achieved with screenings every 2 years, averting almost half of the false positives. It considered the rising number of mammography-induced overdiagnoses—cancers that either would not have progressed or for which early discovery and treatment conferred no benefit. Then, fatefully, it changed its recommendation for women in their 40s back to a C rating and increased the recommended screening interval for older women to every two years.

The panel’s intent in this change was to recommend that women in their 40s discuss the benefits and harms of screening with their doctors. The language accompanying the new recommendation is virtually identical to that in the 2002 advice. But because of a redefinition of the C rating that had taken place after the 2002 report, this rating now has negative rather than neutral language associated with it. As a result, the headlines screamed that it was a recommendation against mammography for women in their 40s.

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Mammograms, poor communication, and politics

Thus, misleading wording was directed at a touchstone and emblematic issue. It was introduced into the present supercharged political climate in the US in which every health issue is reflected through the prism of health reform and the budget. In short, they hit the trifecta. It is no wonder that a furor was the result.

The potential damage of this poorly timed and worded report is surprisingly large. Many women are confused and upset. The task force is discredited and even endangered. The Agency for Healthcare Research and Quality, which sponsors the task force, is threatened and has distanced itself from the task force. By extension, perhaps the entire health reform effort is damaged. It is a stunning development.

Lessons learned? This fiasco may not have been preventable, but a better appreciation of the politics of breast cancer and of health reform might have helped. More careful wordsmithing and timing was certainly called for. Overall, it is a stinging lesson about the surprising importance and potentially devastating consequences of changing an arcane definition of an obscure rating system used by a prominent scientific advisory panel.

BMJ, March 13, 2010