The problematic breast cancer screening recommendations

Breast Cancer Awareness Month may be behind us, but as the second leading cause of cancer death for women, our vigilance in preventing the disease and finding a cure must never cease.

Patients and doctors have long relied on early detection as a means of minimizing the mortality rate and increasing longevity for those diagnosed with breast cancer, since the survival rate is an astonishing 93 to 100 percent when the disease is caught early (stages I or II).

For this reason, the latest screening recommendations frightened and alarmed women and doctors alike.

{mosads}In April 2015, the U.S. Preventative Services Task Force (USPSTF) released draft recommendations restating those it released in 2009, namely that mammography be used every two years to screen only women ages 50 to 74 for breast cancer, and that women between the ages of 40 and 49 should only receive a mammogram based on an individual decision to screen, absent a high-risk history.

USPSTF reiterated that there is insufficient evidence to recommend for or against screening women age 75 and older. USPSTF also stated that there is insufficient evidence to determine the effectiveness of 3-D mammography screening and the use of ultrasounds, MRI or other methods for women with dense breasts.

USPSTF’s draft recommendations are problematic for five primary reasons.

First, the recommendations have the practical effect of rationing preventative medical care by limiting those women considered an approved candidate for the screening, thereby delaying preventative screenings and impeding early detection, which will result in an increase in late-stage diagnoses, limitation on treatment options, decreased quality of life and increased mortality rates. According to the American College of Radiology (ACR), women in their 40s account for about 40 percent of the years of life lost to breast cancer and the most lives are saved with annual mammography beginning at age 40. What’s more, more years of life are saved for women who receive a mammogram every year rather than every other year, and population-based studies show that breast cancer death decreases by 25 to 31 percent among women invited to screening, but by 36 to 48 percent for women who are actually screened.

Second, USPSTF’s recommendations have a tangible, practical impact on many women, particularly those women between the ages of 40 and 49. By relying on USPSTF’s recommendations, insurance companies could use this to limit coverage for routine mammograms to women in the 40 to 49 age group, affecting approximately 22 million women, including 2.8 million African-American women, who have the highest mortality rate for breast cancer. According to Avalere Health, an independent, nonpartisan healthcare advisory company, USPSTF’s draft recommendations could lead to millions of women ages 40-49 losing their insurance coverage for mammograms, and, simply put, many women in this country cannot afford to pay hundreds of dollars for a mammogram.

Third, the draft recommendations continue to fan the flames of confusion among doctors and patients alike. With the USPSTF, American Cancer Society (ACS), and American College of Obstetricians and Gynecologists (ACOG) all offering different recommendations, there is a lack of consensus, and inconsistencies in data, research and statistics. As of Oct. 20, 2015, ACS recommends that women begin annual mammograms at age 45, with biennial mammograms beginning at age 55, and ACOG continues to recommend that annual screenings begin at age 40 for all women. Before patients and providers embrace a significant departure from well-established medical guidelines, it is important to have sufficient data, research and consensus to support the changes — all of which are currently lacking.

Fourth, there is the potential that lawmakers could seek to give USPSTF’s recommendations legal effect. As it stands now, USPSTF is an advisory committee commissioned to provide recommendations and feedback to the Department of Health and Human Services. However, given that the Affordable Care Act (ACA) created a requirement that an A or B rating from USPSTF is automatically covered by private insurance, there is serious concern that insurers will not cover or cease to cover anything with a lower grade. Or of further concern is that Congress — in the future — could give greater power to USPSTF or enact legislation making its recommendations the final word on what insurance companies will — and do not — have to cover.

Fifth, the recommendations interfere with the sacrosanct doctor-patient relationship and expose a doctor to potential medical malpractice liability. Because there are conflicting recommendations among USPSTF, ACS and ACOG, it is unclear which recommendation would be used to establish the appropriate standard of care. Accordingly, a hold harmless provision — like the one added to the legislation repealing the Medicare sustainable growth rate — needs to be specifically applied to breast cancer screenings and mammography.

As a retired OB-GYN, my goal — always — was to provide high-quality, evidence-based care, consistent with professional clinical guidelines. The present lack of consensus, however, has created an incredibly challenging situation for practicing physicians as they navigate the conflicting information and seek to provide best and most appropriate care to their patients.

Until there is consensus and sufficient data to support USPSTF’s recommendations, we should continue to err on the side of early detection. Accordingly, I urge my former colleagues to pass the Protect Access to Lifesaving Screenings (PALS) Act (H.R. 3339 and S. 1926), bipartisan legislation that places a two-year moratorium on implementation of USPSTF breast cancer screening recommendations — so that we can analyze the research, arrive at a medical consensus, and save women’s lives.

Gingrey, M.D., is a senior adviser at the District Policy Group, a boutique policy and lobbying practice within Drinker Biddle & Reath. Dr. Gingrey is a former U.S. congressman who served Georgia’s 11th congressional district from 2003 to 2015. The views expressed are the author’s own and are not an endorsement of the legislation mentioned.