Birmingham, AL (PRWEB) January 17, 2010
The physician must be responsible for treating the individual patient. Guidelines that are based on data that excludes certain groups that comprise a significant number of our patient population must not be viewed as universally accepted practice. It is up to concerned physicians to make certain that employers, policy makers, regulators, and the public are aware of these critical limitations, and to continue to advocate for their patients, as individuals.
R. Bruce Shack, M.D., President, Southern Medical Association
Michael C. Gosney, M.D., J.D., M.B.A., Chair, Coordinating Committee on Advocacy
Breast Cancer Screening: who will advocate for the patient?
In November 2009, the U.S. Preventive Services Task Force issued breast cancer screening recommendations. These recommendations were based on a case-based analysis, and were “intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services.” It quickly became apparent that these recommendations and the accompanying suggestions for practice would not be universally accepted by clinicians or the public in general, and many quickly rose up to cite these recommendations as the first wave of health care rationing that could become ubiquitous under health care reform.
Physicians strive to provide the best care possible for their patients. The Task Force provides information to inform clinical decisions related to cancer screening. The clinician is concerned with the individual patient, whereas the Task Force is concerned with populations and whether definitive evidence exists to support screening within certain demographic groups. A lack of evidence to support screening for a particular group does not necessarily mean that such screening is not beneficial; it means that there is simply no controlled study (discounting anecdotal evidence of which we are all aware) to support screening for that particular portion of the patient population. In the absence of clear and timely data, recommendations should be withheld or qualified.
The Task Force admits that the study upon which the recommendations are based has certain limitations. These limitations are likely to be more significant for some clinicians and their patients, depending on the region of the country in which they practice and the individual patients who populate their practices. In particular, women with a genetic susceptibility or family history of breast cancer and black women are not included in the cohort upon which these recommendations are based. These women have a higher risk of breast cancer and of more aggressive types of breast cancer, and would benefit from more frequent screening and screening at a younger age. Making a broad statement about screening without addressing these alternate populations is hazardous.
The Task Force states that their recommendations are in part meant to limit unanticipated, negative consequences of routine mammograms including patient anxiety, false –positive results, biopsies in patients without cancer and diagnosis of lesions that may not be clinically significant. A recent study, not referenced by the Task Force, by Gierisch et al evaluated factors and barriers associated with yearly mammogram screening compliance in women aged 40-49. They found 26.1% of women were nervous about the results of mammograms. However there were other competing reasons for annual noncompliance, including “not thinking mammograms are necessary” (12.6%), “too busy” or “forgot” (40% and 43.3% respectively). The well published controversies and ambiguous recommendations for screening mammography of women in their 40’s could also result in noncompliance for these patients, including those patients for whom screening is indicated based on their individual family history, genetics, or ethnic origin. This is another important “unquantifiable” consideration that we as health professionals must consider when evaluating Task Force recommendations and their unintended consequences.
It is critical that we carefully examine the limitations of these recommendations and their unintended consequences, and as physicians, consider how the recommendations apply on an individual patient basis. It is also critical that payers are aware of these limitations, so that patients who need screening outside of recommended guidelines will still be covered. Future recommendations and/or guidelines should be applicable to all patient populations, or should qualify within the recommendation itself the patient population to which it applies. The U.S. Preventive Services Task Force has provided clinicians, employers, policy makers, and regulators with information that may potentially result in denial of breast screening to patients who would benefit from screening. It is up to concerned clinicians to make certain that employers, policy makers, regulators, and the public are aware of these critical limitations, and to continue to advocate for their patients.
Peter Kragel, M.D., Professor and Chair, East Carolina University Brody School of Medicine
Lisa Bellin, M.D., Clinical Associate Professor, East Carolina University Brody School of Medicine
*The Southern Medical Association is a multi-specialty physician based professional association which has provided post graduate continuing medical education and development to physicians since 1906. For more information visit http://www.sma.org.
Mandelblatt JS, Cronin K, Bailey S, Berry D, Konin H, Draisma G ,Huang H, Lee S, Munsell M, Plevritis S, Ravdin P, Schechter C, Sigal B, Stoto M, Stout N, Ravesteyn N, Venier J, Zelen M, Feuer E. Effects of mammography screening under different screening schedules. Model estimates of potential benefits and harms. Ann Intern Med 2009;151:738-747
Mandelblatt JS, Liang W, Sheppard VB, Wang J, Isaacs C. Breast cancer in minority women. In: Harris J, Lippman M, Morrow M, Osborne CK, eds. Diseases of the Breast. 4th ed. Philadelphia: Lippincott Williams & Wilkin; 2009.
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Gierisch JM, O'Neill SC, Rimer BK, DeFrank JT, Bowling JM, Skinner CS.Factors associated with annual-interval mammography for women in their 40s. Cancer Epidemiol. 2009 Jul;33(1):72-8. Epub 2009 May 29.
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