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Expert Agreement With New Mammography Guidelines Clouded by Politics

3 December 2009 1:41 pm
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A House of Representatives hearing that was supposed to look at the science behind a controversial policy on mammography yesterday erupted in a donnybrook.

Conservative members of the Energy and Commerce Subcommittee on Health pounced on recommendations to cut back on mammography—issued on 16 November by the U.S. Preventive Services Task Force, a government-appointed panel of health advisers—as an example of the bad things that would happen if current plans for health reform go forward. The task force advised that healthy women should not begin routine mammograms until age 50 (the previous advice was to begin at 40). Even then, it said, mammograms should be done only every other year, as opposed to annually. The task force also recommended that doctors not teach healthy women to do regular breast self-exams. The reason in both cases: aggressive screening tends to produce needless psychological stress, biopsies, and surgery—harms that outweigh the benefits for younger women.

Representative Joe Barton (R–TX) blasted the task force’s retreat from aggressive screening as a kind of medical “rationing”—a step along “the path of socialization of medicine in this country.”  Barton and others argued that the task force was trying to cut medical costs and that its new advice would cause some women to die. Republican members of the subcommittee also said the new advice was a foretaste of what the House-passed health care reform bill would bring, if enacted. Representative John Dingell (D–MI), a backer of the health reform bill, shot back that he was amazed to hear such “fairy tales. … It is like listening to the Brothers Grimm.”  Dingell deplored “the scare tactics.” And then the experts spoke.

The key witnesses—task force leaders Diana Petitti, a biomedical informatics expert at Arizona State University, Tempe, and Ned Calonge, chief medical officer at the Colorado Department of Health in Denver—were peppered with questions about why their group had decided to reverse earlier advice on mammography. (A 2002 task force, with different members, recommended that annual mammography start at age 40.) Petitti and Calonge said that the decision to deemphasize mammography was based on a fresh review of the best and most recent evidence. Some members of Congress pressed them to acknowledge that the task force had an unstated goal—to cut medical costs. Both denied it. “Cost played no role in our considerations,” said Petitti. She and Calogne conceded that they could have done better in a couple of ways, however. They said that the panel didn’t fully involve “stakeholders” in its review and that the recommendations were poorly worded. Rather than discourage mammography for women in their 40s, what they meant to say, according to their testimony, was: “The decision to have a mammogram for women in their 40s should be based on a discussion between a woman and her doctor.”

Otis Brawley, a breast cancer expert and chief medical officer of the American Cancer Society, said that ACS disagreed with the recommendation that regular mammograms be delayed until age 50. An ACS expert group reviewed the evidence in 2007 and reached a different conclusion, he said: Women gain more than they lose if they start mammograms at age 40. “Experts can look at the science and disagree,” Brawley explained. But he endorsed the task force’s conclusion that monthly breast self-exams produce too many false alarms and unneeded biopsies. Instead, ACS advises “breast awareness,” an approach that encourages women to be alert to physical changes but not to search rigorously for them.

A non-scientist delivered what may have been the sharpest critique of the day. Fran Visco,  a lawyer, 22-year breast cancer survivor, and president of the National Breast Cancer Coalition, pleaded for less emotion and more reason. She said her organization supported the task force and its scientific approach. She added that there’s nothing new about the furor it caused:

Many in the public were shocked by these changes in breast cancer screening guidelines, but these guidelines and this controversy are not new. … A National Institutes of Health consensus panel came to similar conclusions in 1997. In fact, historically, the scientific evidence has not supported the breast cancer screening methods that have been vigorously promoted in our country. Today, we have even more evidence and a greater understanding of breast cancer, but it appears that once again, emotion and conventional wisdom are taking precedence over science, evidence, and progress. Because a health message has been given over and over again and has become rooted in the public consciousness does not make it correct. … Too many times … beliefs have taken hold when there was in fact no real evidence behind them, and these actions resulted in harm to women.

Two other witnesses—Donna Sweet of the American College of Physicians and Jennifer Luray of the Susan G. Komen for the Cure foundation, a patient advocacy group, offered support for the task force but were concerned about the public response. Sweet said her organization recommends that women between age 40 an 49 consult with their doctor and make an individual decision about mammography. Luray said that "there is enough uncertainty about the age at which mammography should begin and the frequency of screening that we would not want to see a change in policy for screening mammography at this time."

Subcommittee Chair Frank Pallone (D–NJ) ended the session by saying that he had hoped to examine the evidence behind the task force findings but that the whole issue had become “totally politicized.” He apologized, “on behalf of Congress."

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