When Evidence Collides With Anecdote, Politics and Emotion: Breast Cancer Screening

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That’s the title of an editorial in this week’s Annals of Internal Medicine (subscription required – even though the article is marked as “free” on the Annals home page.)

It’s a reflection on the US Preventive Service Task Force’s recommendations on breast cancer screening from last fall. The Annals editors remind readers:

“Although some subspecialty organizations advocate more aggressive routine breast cancer screening, the update actually aligned the USPSTF recommendations more closely with guidelines from the American College of Physicians, the World Health Organization, and the United Kingdom’s National Health Service.”

Other excerpts:

“Annals posted a survey on our Web site to solicit readers’ impressions. The responses suggest that clinicians are more inclined to change what they do in light of the new recommendations than are members of the general public. …

Clinicians who offer advice compatible with the new USPSTF recommendations are likely to meet resistance. Most women who responded to the survey resolved to continue as routine the practices that the USPSTF advises against being routine. …

The Task Force’s charge is to provide evidence-based, population-level guidance. Only rarely does evidence unequivocally support a single, definite “one-size-fits-all” recommendation. As the breast cancer recommendations so vividly illustrate, clinicians must often invoke the art of medicine to apply available evidence to an individual patient. Before these most recent guidelines, many clinical encounters about breast cancer screening probably involved little more than the physician handing the patient a mammography referral. Going forward, these interactions will surely involve more discussion about risks, harms, benefits, and preference. The Task Force’s intent was to motivate such rational discussion, not to ration care. …

Because the USPSTF issued recommendations that were politically unpopular among some constituents, there have been calls to curtail this independent body’s work. If the USPSTF sinks in turbulent waters whipped up by emotion, anecdotes, and politics, Americans should mourn its loss.”

Finally, the Annals editors referred to “a media cacophony” – a phrase I’ve used in reference to coverage of this episode. They wrote that “the media and politicians presented the breast cancer screening recommendations as a major departure from existing guidelines that heralded an age of rationed care in the United States. Confusion, politics, conflicted experts, anecdote, and emotion ruled front pages, airwaves, the Internet, and dinner-table conversations.”

This episode was – and still can be – a golden opportunity for informing people about evidence – and for shared decision-making. This won’t be last collision between evidence and anedote/politics/emotion. Will we be any smarter next time?

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Chrs Flowers

March 8, 2010 at 11:50 am

Gary. Yours is a great and insightful blog, with helpful analyses of current healthcare issues.
My comments on the above story is as follows –
While the editorial in the Annals of Internal Medicine claims to be unbiased, there is no real addressing of the criticisms of the USPSTF recommendations made by breast cancer specialists, such as the American College of Radiology, or the American Cancer Society.
While (they) claim to be aligning their guidelines more to the European models, and more specifically to the UK National Breast Screening Program (NHS BSP), they fail to take into account that these guidelines are based more on what the country can afford in terms of preventative health-care, with costs per cancer and quality life year measurements, than on the real science.
For example, there is plenty of evidence that screening women under 50 years is efficacious, acknowledged by the USPSTF, but according to their ‘modeling’ it was probably not worth screening this group due to the ‘harms’ of screening. Unfortunately they got their figures wrong on the assumptions made for their models, and if they had the up to date data, their modeling would have shown much more evidence for screening the under 50’s.
I worked in the NHS BSP for 20 years before practicing as a breast imager in the USA, and (we) would have preferred the UK government to pay for annual mammograms in women under 50 years due to the number of productive years of life saved, rather than increasing the upper limit for screening (which at the time was the politically expedient thing to do).
Emotion does need to be taken out of the debate, but let the debate be about the science, and stop confusing women and primary care with ever changing guidelines. Cancer prevention and risk reduction is important, and someone needs to be an advocate for women here.