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Informative report on mammogram recommendations could have quantified lives saved

Mammogram. (Rui Vieira/Press Association via AP)

The controversy over when a woman should get mammograms is about to heat up again.

The U.S. Preventive Services Task Force, an independent panel of experts whose members are appointed by the federal government, issued a final set of  recommendations late Monday saying that women between the ages of 50 and 74 should get routine screening once every two years. The task force’s guidelines are important because insurers and government programs often follow the panel’s recommendations in deciding whether to cover certain preventive services.

The task force’s final recommendation is likely to be controversial because some other groups say the screening should start earlier. The American Congress of Obstetricians and Gynecologists, for example, recommends that regular screenings begin at age 40, while the American Cancer Society calls for women to start yearly screening at age 45 and then move to screening every two years starting at age 55.

Congress has sided with proponents of earlier screening. Last month, in anticipation of Monday’s release of the task force’s final recommendation, lawmakers took preemptive action: It directed insurers to ignore the task force’s latest guidelines and, instead, to rely on its 2002 recommendation. That called for annual mammograms to begin at 40. As a result of the congressional action, women in their 40s will continue to be able to get annual mammograms at no cost.

The differences over when to start regular screening reflect the growing concern that the benefits of mammograms may have been oversold, and that they don’t outweigh the anxiety and potential harm caused by over-diagnosis and false positives from the tests.

The debate over when to start regular screening involves only women of “average risk” who don’t have specific risk factors for breast cancer such as the BRCA1 and BRCA2 genetic mutations or a family history of the disease. They’re also not aimed at diagnostic mammography, which takes place once a woman has a symptom such as a lump. The screening recommendations are not binding on doctors, hospitals or insurers.

In releasing its final recommendations, the task force confirmed an earlier guidance it issued that said screening mammography had the greatest benefit for women ages 50 to 74. For women in their 40s, the likelihood of benefit is less and the potential harms are proportionally greater, it said. The most serious potential harm is unneeded treatment for a type of cancer that would not have become a threat to a woman’s health during her lifetime.

The congressional action, which was included in the recently enacted spending law, has drawn criticism from some experts.

“The U.S. Congress thinks it’s perfectly acceptable, even preferred, for a scientific document from 14 years ago to guide coverage policy on screening for breast cancer in women,” says Kenneth Lin, a Georgetown University family medicine doctor who teaches preventive and evidence-based medicine.

Part of the problem is the common perception that women deserve free mammogram coverage and that the scientific community is basing its decision on cost or rationing, said Lawrence Gostin, a Georgetown University law professor and expert on public health.

Fran Visco, president of the National Breast Cancer Coalition, said the task force’s guidelines for women in their 40s — that they should discuss whether to get mammograms with their doctors and make individual decisions — come closest to following the evidence accumulated over the past three decades. Women should trust that process, she said.

Despite the decades of marketing of mammography to women, “women are capable of understanding the complexities of the issue, evaluating the evidence and making their own health decisions,” she said in a statement.

“At some point we will have to decide that we are not going to pay for interventions that lack a high level of medical evidence,” she said. “At this time, what does concern us very much are attempts by Congress to interfere with the makeup and process of the US Preventive Services Task Force.”

The task force first suggested in 2009 that breast cancer screening begin at 50 instead of 40, touching off enormous criticism. In 2010, Congress passed the Affordable Care Act, which required that certain preventive services be provided for free — if those services got a strong recommendation from the task force. But it included an amendment that effectively directed insurers to use the 2002 recommendations for mammograms.  That meant that women who were 40 and older could get mammograms at no cost.

In April 2015, the task force came out with its latest draft guidance, basically reaffirming its 2009 recommendations that the greatest benefit of mammography screening is for women between 50 and 74.

Worried that millions of women under 50 could lose their free annual mammogram coverage if the guidelines became final, several health-care groups, including ACOG, the American College of Radiology and the Susan G. Komen Foundation, lobbied Congress to block that from happening.

Language was included in the spending bill that says any recommendations of the task force related to breast cancer screening, mammography and prevention refers to those “issued before 2009.”

Sen. Barbara Mikulski (D-Md.) was among the lawmakers who pushed for the language to be included. In a statement, she said her number one priority was to ensure that women can get mammograms if they and their doctors decide it’s the right thing to do. “This means making sure that cost is not a deterrent to care,” she said.

Several groups that lobbied for congressional action said in a statement last month that the task force recommendations conflict with those of other organizations. This results in confusion and puts more than 22 million women at risk of losing of losing insurance coverage for mammograms.

This post has been updated.

New breast cancer screening guidelines at odds with Congress

Our Review Summary

Nurse Assisting Patient Undergoing MammogramThe story provides a good overview of new recommendations from the U.S. Preventive Services Task Force (USPSTF) on when, and how often, women should receive mammograms to screen for breast cancer. The story summarizes the long-running debate over mammogram recommendations, particularly congressional action on the issue. The story also discusses the differing advice that various organizations provide on when women at average risk of breast cancer should begin mammogram screening, though the story would have been stronger if it had more fully explored both the benefits and potential harms associated with women starting mammogram screening early or having the tests more often (something that a competing New York Times story on the recommendations does well). The story also offers a good discussion of issues related to what the USPSTF recommendations may mean for insurance coverage of mammograms, though it does not tell readers how expensive mammograms may be without insurance.

 

Why This Matters

Breast cancer screening is a big deal. As the CDC notes, “Not counting some kinds of skin cancer, breast cancer in the United States is the most common cancer in women, no matter your race or ethnicity.” In 2012 alone, 41,150 women died of the disease. Breast cancer also has a profound impact on the economy, with researchers estimating that it costs the U.S. billions of dollars each year. In other words, it affects the health and well-being of millions of patients and their loved ones, as well as having an adverse impact on the economy. News that relates to the early detection and treatment of breast cancer is clearly news worth covering, particularly when it could inform the decision-making of women and health professionals — and have an effect on women’s access to screening.

Criteria

Does the story adequately discuss the costs of the intervention?

Not Satisfactory

The story does address how the USPSTF recommendations may affect insurance coverage of mammography screening, as well as related congressional action mandating that insurers cover such screening. However, the story does not tell readers the bottom line: how much would a mammogram cost if it were not covered by insurance? While we found varying estimates, a 2011 paper stated that the overall cost of a mammogram was $266 — a considerable sum, and likely out of reach for many women. This was a shortcoming of both the Washington Post and New York Times stories.

Does the story adequately quantify the benefits of the treatment/test/product/procedure?

Not Satisfactory

The story does not offer any detailed information on the potential benefits associated with mammogram screening. Instead, the story uses vague language, describing the USPSTF’s recommendations as saying that “screening mammography had the greatest benefit for women ages 50 to 74” and that “the likelihood of benefit is less” for women in their 40s. Exactly how much different are the potential benefits for these groups? That’s an important point, and the story doesn’t tell us.

The story does note that the USPSTF recommendations are aimed only at women with an average risk of breast cancer, and it attempts to explain what that means, noting that it refers to women “who don’t have specific risk factors for breast cancer such as the BRCA1 and BRCA2 genetic mutations or a family history of the disease.” That’s useful information for readers, but the story could have noted that there are other factors that place women at elevated risk. A history of prior breast surgery, especially if the pathology demonstrated atypical hyperplasia [an abnormal overgrowth of cells] significantly increases the risk of a subsequent breast cancer. In addition, a woman’s menstrual history, age at first pregnancy, and other factors also influence risk. There are several risk assessment models that are widely available, but are underutilized, to help women and their physicians assess risk. It would have been helpful to at least acknowledge this, as there remains a lot of confusion over just what constitutes “average risk.”

Does the story adequately explain/quantify the harms of the intervention?

Satisfactory

The story addresses harms briefly in two places. In one place, the story refers to “the anxiety and potential harm caused by over-diagnosis and false positives,” though it doesn’t explain what over-diagnosis or false positives mean (potentially leaving many readers in the dark). The story also notes that “The most serious potential harm is unneeded treatment for a type of cancer that would not have become a threat to a woman’s health during her lifetime.” But it doesn’t give readers any idea of how serious this harm might be, or how common this scenario is. In short, the story does enough to earn a Satisfactory rating, but could have (and should have) done more. It’s worth noting that the New York Times piece did a top-notch job discussing harms.

The story does, however, make clear that women should be informed consumers, and that — if well-informed — women should have the authority to weigh potential benefits against potential harms and make their own decisions about when and how often to get screened. That’s an important point, and one worth making.

Does the story seem to grasp the quality of the evidence?

Not Satisfactory

There is no specific study to evaluate or discuss in a story like this one; the USPSTF’s recommendations are based on an evaluation of all the available research literature on breast cancer screening and mammography. However, the story could have simply said that. As it is, while the story does tell readers what the USPSTF is, it doesn’t say anything about what the task force based its recommendations on.

Does the story commit disease-mongering?

Satisfactory

No disease mongering here.

Does the story use independent sources and identify conflicts of interest?

Satisfactory

The story incorporates input from several independent sources. Comments from Fran Visco of the National Breast Cancer Coalition are worth repeating: “Women are capable of understanding the complexities of the issue, evaluating the evidence and making their own health decisions.”

Does the story compare the new approach with existing alternatives?

Satisfactory

The alternatives in a story like this one are the recommendations from other organizations. And the story does explain varying recommendations from the USPSTF and two other groups: the American College of Obstetricians and Gynecologists, and the American Cancer Society.

Does the story establish the availability of the treatment/test/product/procedure?

Satisfactory

The story makes clear that the use of mammograms as breast cancer screening tools is longstanding and well established. The story also discusses insurance coverage issues that would affect availability for many women.

Does the story establish the true novelty of the approach?

Satisfactory

The story does tell readers that the new recommendations on mammograms and breast cancer screening are consistent with the USPSTF’s 2009 recommendations — which triggered a fierce (and still ongoing) debate over the issue. The story also offers a good primer on congressional action related to the debate, particularly as pertains to legislation that mandates insurance coverage of mammograms for breast cancer screening.

Does the story appear to rely solely or largely on a news release?

Satisfactory

The story clearly includes original reporting and goes beyond what would be found in a news release.

Total Score: 7 of 10 Satisfactory

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