USPSTF recommendations and the ability to choose

When the U.S. Preventive Services Task Force (USPSTF) issued its 2009 recommendation for a limited mammography screening strategy, it was met with a flurry of controversy. By endorsing routine mammography only on a biennial basis for women ages 50-74, as opposed to annual screening starting at 40 as the American Cancer Society and others recommend, the USPSTF recommendations would cost thousands of lives, according to critics.

After years of debate, would the USPSTF change its tune? The answer is “no,” as the USPSTF released a draft update of its recommendations earlier this week that was largely a rehash of the 2009 guidelines. The task force’s draft update gave a “B” recommendation to screening mammography every two years for women ages 50-74 and a “C” recommendation for screening of women ages 40-49.

The task force claimed that while extending biennial screening to 40-49 year-olds would prevent one additional breast cancer death for every 1,000 women screened, data from the Breast Cancer Surveillance Consortium showed it would also result in a rash of overdiagnosed tumors, unnecessary biopsies and false-positive anxiety.

A joint statement from the American College of Radiology (ACR) and the Society of Breast Imaging again called out the USPSTF for putting patients’ lives at risk, saying the studies backing up the recommendations overestimated the harms and underestimated the benefits of screening. “They ignored more modern studies that have shown much greater benefit,” said Barbara Monsees, MD, FACR, chair of the ACR Breast Imaging Commission, in the statement. “These limitations result in the misrepresentation of the real trade-offs that women and health care providers need to know about in order to make good decisions about screening.”

The USPSTF did say that certain women at a higher risk due to family history might benefit more from screening in their 40s, and that it should be an individual decision. Writing for the NPR’s “Shots” health blog, Katherine Hobson discussed reporting on the USPSTF recommendations as a woman in her 40s and facing this choice herself. While her reaction to the 2009 guidelines was concern about overdiagnosis and a hesitancy to seek screening, now that she has a child, her individual risk-benefit analysis had shifted and she was planning on getting a mammogram this year.

“In other words, then and now, I weighed the benefits and the risks and made my own decision, which is exactly what the USPSTF suggests,” wrote Hobson.

Patients aren’t alone in making choices. Physicians also make choices about what they advise patients, and the day after the USPSTF released its draft update, a study presented at the American Roentgen Ray Society 2015 Annual Meeting in Toronto showed a vast majority of breast surgeons recommend screening for their 40-49 year old patients in spite of the USPSTF. Of 288 surveyed surgeons, 88 percent of breast surgeons and 82 percent of general surgeons continue to recommend annual mammography starting at 40 for women with an average risk of cancer.

My biggest concern is for those who might not get to make a choice. A provision in the Affordable Care Act requires that any procedure given a “B” rating or higher by the USPSTF must be covered by private insurers without a copay. Will the “C” rating for screening of women in their 40s jeopardize coverage for women who feel the benefits of screening outweigh the potential harms? Bibb Allen, MD, FACR, chair of the ACR Board of Chancellors, called on the Secretary of the U.S. Department of Health and Human Services to affirm that coverage will not be affected, and millions of women could be affected by the response.

-Evan Godt
Editor – Health Imaging