The world of cancer screening was upended in mid-November when changes in screening recommendations for two common types of cancer, breast and cervical, were announced within a week of each other. Not only did the U.S. Preventative Services Task Force (USPSTF) advise that women wait until age 50 to begin mammography screening, but the American College of Obstetricians and Gynecologists (ACOG) issued revised guidelines for cervical cancer screening, recommending that women wait until they reach the age of 21 to have their first Pap Test. Both groups also recommended less frequent screening, except for higher risk cases. And though the new USPSTF guidelines are based on an in-depth analysis of data that suggests the harms of testing earlier and more frequently outweigh the benefits, they have sparked a great deal of controversy and drawn criticism from some advocacy groups and specialists organizations—some going so far as to say that the new recommendations were politically motivated.
The American Cancer Society (ACS) is one organization that has disagreed with the new USPSTF breast cancer screening recommendations. “Our definition of cancer was given to us by German pathologists in the 1840s after they looked at biopsies from autopsy specimens. Now, 170 years later, we’ve progressed in terms of imaging, in terms of medical diagnostics into what I call the genetic and molecular biologic age, but our ability to define cancer has not progressed beyond the light microscope,” explained Dr. Otis Brawley, chief medical officer of the ACS. “What we need to be able to do eventually is say that ‘this cancer is never going to progress,’ it is not going to spread and invade other organs in the body. But right now we don’t have the molecular tools to predict their behavior.” Brawley concluded: “Our view is that breast cancer screening saves lives and women aged 40 and above should get a high quality mammogram and clinical breast exam on an annual basis.”
And on December 2, the USPSTF’s top officials, including Dr. Ned Calonge, were summoned before a Congressional committee. Calonge, chairman of the USPSTF and chief medical officer of the Colorado Department of Public Health and Environment and associate professor of family medicine and of preventive medicine and biometrics at the University of Colorado Health Sciences Center in Denver, defended the task force and its revised recommendations but acknowledged that portions of the mammography recommendations, specifically those pertaining to women aged 40-49, were poorly phrased and “did not say what the task force meant to say.” Calonge then clarified the USPSTF’s stance. “Screening starting at age 40 should not be automatic, nor should it be denied,” he said in his testimony. “What we are saying is that the decision to have a mammogram for women in their 40s should be based on a discussion between a women and her doctor. Many doctors and many women, perhaps even most women, will decide to have mammography screening starting at age 40. The task force supports those decisions.” Calonge said the task force is committed to changing the way it communicates to ensure that “this kind of miscommunication does not occur in the future.”
Calonge also said the task force voted on the recommendations in June 2008—well before the presidential election and the national health reform debate that followed, adding that the release date of the recommendations was determined by the Annals of Internal Medicine’s publication schedule. “We are well familiar with the ruthless horror of cancer, and the role that detection and treatment plays,” he testified. “We certainly know that mammography saves lives. However, our job as the task force is to rigorously review scientific evidence. Politics play no part in our processes. Cost and cost-effectiveness were never considered in our discussions.”
“It’s unfortunate that things like this become so politicized, that science can’t just be science,” said Judy Ockene, a disease prevention specialist at the University of Massachusetts Medical School and a member of the USPSTF who helped draft the new breast cancer screening recommendations. “I found it personally frustrating to see so much of a response and people being maligned and it being said that they’re doing this for their own self-interest. There’s not one member of that task force that gets any money out of it.” Ockene’s term on the task force ended a year ago.
However, not everyone has been critical of the task force. “I think it’s a coincidence that this (the mammogram recommendation) came out when it did, right in the middle of the healthcare reform discussion,” said Dr. Robert J. Barnet, senior scholar in residence at the Center for Clinical Bioethics at Georgetown University in Washington, D.C. “It’s a good panel, one that was dedicated to getting the right answer to what should be done about this.”
