The Lynx Group

Breast Cancer Screening Recommendations: Evidence, Fear, and Politics

October 2010, Vol 1, No 5

In November 2009, the US Preventive Services Task Force (USPSTF) published new recommendations about routine breast cancer screening mammography.1 If followed, the new recommendations would substantially reduce the use of the procedure among women aged 40 to 49 years.2 The recommendations were touted by some leading health policy researchers as “rational”3 and “objective.”4 Yet, the positive evaluations were overwhelmed by an avalanche of negative reactions from professional associations, patient advocates, and elected officials from both political parties.5 Within a month, the Senate agreed by voice vote to an amendment that effectively required the federal government to ignore the Task Force’s recommendations.6

Lessons Learned
It is not unprecedented for new practice guidelines to generate powerful opposition. Professional and advocacy opposition, along with financial interests and ideological concerns about government “rationing,” may create barriers to the implementation of comparative effectiveness research (CER) and evidence-based medicine (EBM), particularly when existing practices are challenged. This seems more likely when health policy issues are highly salient to industry, professional, and consumer organizations.

With the adoption of US healthcare reform and the future expansion of government-funded health insurance, healthcare costs will continue to be a major concern for policymakers. Both governmental and private purchasers of care will continue to have to make decisions about what services to pay for. Although analysts disagree about the potential for CER to reduce healthcare spending,7-9 the idea of using evidence to improve healthcare policy decisions enjoys support from a broad range of actors.8,10-13 Nevertheless, the strong negative reaction to the 2009 mam mography recommendations from the USPSTF is a powerful signal that the implementation of CER and EBM can encounter great resistance, particularly when this research suggests that broadly accepted healthcare technologies that have been promoted by the healthcare community and patient advocates may not be worth the cost. Although, to date, controversies regarding practice guidelines have been unusual, the conditions that produced the objections in the mammography case could become more important, and more common, as the use of CER and EBM is extended.

The USPSTF did not base its mammography recommendations on possible cost-savings, but proponents of CER and EBM often claim that this research will reduce spending by eliminating unnecessary care.8 The reactions to the mammography recommendations suggest that the health services research community needs to understand better what the public believes about evidence and ways that healthcare costs might be constrained. Greater focus on likely public reactions may encourage the research community and entities like the USPSTF to work with the media, anticipate possible misinterpretations, and reduce public anxiety. Leaders at the Agency for Healthcare Research and Quality and the USPSTF appear to be moving in that direction already by providing additional opportunities for public comment on forthcoming recommendations, which will be posted at www.preventiveservices.ahrq.gov.14

Providing such opportunities for public comment may help the health services research community build support for basing policy decisions and practice guidelines on a strong evidence base and perhaps increase understanding of and confidence in the research base for such decisions. The new health reform legislation calls for establishment of a methodology committee to advise the Patient-Centered Outcomes Research Institute, which is charged with conducting CER. The methodology committee is required to “develop and improve the science and methods of comparative clinical effectiveness research.”15 Establishing the credibility of its methods among a broad array of stakeholders will not insulate the new institute, or health services researchers more generally, from controversy. Never the less, establishing broader support for the value of health services research, coupled with sustained efforts to communicate more effectively with the public, is crucial as the United States grapples with how best to improve the quality and efficiency of its health system.

References

  1. US Preventive Services Task Force. Screening for breast cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 151(10):716-726.
  2. Kerlikowske K. Evidence-based breast cancer prevention: the importance of individual risk [editorial]. Ann Intern Med. 151(10):750-752.
  3. Reinhardt UE. The uproar over mammography. New York Times. November 20, 2009. Economix, Explaining the Science of Everyday Life.
  4. Wilensky GR. The mammography guidelines and evidence-based medicine. http://healthaffairs.org/blog/author/gail/. Accessed March 22, 2010.
  5. Liberals and mammography: Rationing? What rationing? (Review and Outlook). Wall Street Journal. November 24, 2009:A22. http://online.wsj.com/article/NA_WSJ_PUB:SB10001424052748704779704574552320222125990.html. Accessed August 16, 2010.
  6. Herszenhorn DM. Senate blocks use of new mammogram guidelines. New York Times. December 3, 2009. http://prescriptions.blogs.nytimes.com/2009/12/03/gop-amendments-aim-at-new-cancer-guidelines/. Accessed August 16, 2010.
  7. Callahan D. Controlling costs: do as business does. Health Care Cost Monitor. January 29, 2010. http://healthcarecostmonitor.thehastingscenter.org/daniel-callahan/controlling-costs-do-as-business-does/. Accessed August 16, 2010.
  8. Fisher ES, Bynum JP, Skinner JS. Slowing the growth of health care costs-lessons from regional variation [perspective]. N Engl J Med. 2009;360(9):849-852. H. R. 3590.
  9. Marmor T, Oberlander J, White J. The Obama administration's options for health care cost control: hope versus reality. Ann Intern Med. 2009;150(7):485-489.
  10. Cannon MF. A better way to generate and use comparative-effectiveness research. Policy Analysis. February 6, 2009;632:1-21. http://www.cato.org/pub_display.php?pub_id=9940. Accessed August 16, 2010.
  11. Chassin MR, Brook RH, Park RE, et al. Variations in the use of medical and surgical services by the Medicare population. N Engl J Med. 1986;314(5):285-290.
  12. Iglehart JK. Prioritizing comparative-effectiveness research-IOM Recommendations. N Engl J Med. 2009;361(4):325-328.
  13. Wennberg JE. Dealing with medical practice variations: a proposal for action. Health Aff (Millwood). 1984;3(2):6-32.
  14. US Preventive Services Task Force. Opportunities for Public Comment. www.uspreventiveservicestaskforce.org/tfcomment.htm. Accessed August 16, 2010.
  15. Patient Protection and Affordable Care Act. P.L. 111-148. H. R. 3590.

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