Federal task force takes heat over cancer screening advice

Robin Wulffson MD's picture
breast cancer, prostate cancer, cancer screening, U.S. Preventive Services Task
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For much of its 27-year history, the U.S. Preventive Services Task Force (USPSTF) has taken the stance that routine cancer is beneficial; however, recently it has taken the viewpoint that routine screening may be doing more harm than good. The reversal of the panel of primary care doctors came as a result of their review of a growing body of research that reports that some early screening may harm more people than it helps. Physicians and patients are not convinced; thus, they oppose the USPSTF’s recommendation that less screening be done for conditions such as screening mammograms for breast cancer and the prostate specific antigen (PSA) test for prostate cancer.

Dr. Ned Calonge has come face to face with public opposition to the panel’s viewpoint. Dr. Calonge, a Colorado family physician, presided over the U.S. Preventive Services Task Force two years ago when it recommended that most women under 50 could avoid screening mammograms. Many breast cancer patients were enraged; they noted that early screening had allowed them to conquer the dreaded disease. A public uproar ensued. "We blew the message," said Dr. Calonge. He added, "The nuance was completely gone."

Two men phoned in death threats to Dr. Calonge. Protesters appeared at the showed up by the offices of the government agency that supports the USPSTF. The public outcry slowed down work on a decision to limit prostate cancer screenings as President Obama fought to pass his signature healthcare law and his Democratic party faced a mid-term election challenge in 2010.

"There was a lot of pressure from above to be more careful politically and orchestrate things better," said Dr. Kenneth Lin, who at the time was an officer at the Agency for Healthcare Research and Quality (AHRQ), a Department of Health and Human Services entity that supports the panel. "Everything with the word 'cancer' got shoved back."

Despite the recommendations to reduce screening mammograms, physicians continued to order them and women continued to undergo them. According to the National Committee for Quality Assurance, the number of screening mammograms for women aged 40 to 69 remained about the same in 2010 as it was in 2009, according to the National Committee for Quality Assurance.
"We have a public health measure that we know is effective. Why is it continually being questioned?" said Dr. Carol Lee, breast imaging commission chairwoman at the American College of Radiology

Last March. Dr. Calonge rotated off the panel and Dr. Lin resigned his AHRQ late last year in protest over the delay to prostate cancer screening guidelines, which were only released in October. A White House official noted that Dr. Calonge has attributed the delay in a final decision on prostate cancer screenings to scheduling conflicts.

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Although the USPSTF claims that routine screening may do more harm than good, opponents claim that the recommendations are based on containing spiraling healthcare costs. The general public remains skeptical. A recent Gallup poll found that almost 60% of Americans believed that standard cancer screenings, including mammograms and prostate specific antigen (PSA) blood tests, were performed often enough. Furthermore, 31% felt that they should be conducted more frequently. Only 7% responded that they thought the tests were done too often.

"It's extraordinarily hard to give up the notion that there's a way to protect yourself from dying from cancer... Our goal here is to make it a matter of evidence, not a matter of opinion," said Virginia Moyer, a pediatrician from Baylor College of Medicine, who now chairs the 16-member panel. She added, "Our successes are measured in positives… We are just beginning to approach the negatives."

Following the public outcry over mammograms, UPSTF is seeking a better way to deliver its message; the task force is consulting with powerful consumer interest groups, hiring public relations professionals, and rewriting some of the language in its letter-based recommendations. Currently, the UPSTF issues its recommendations in draft form first and solicits public comment before making them final. In about a year, the public may have a chance to participate in the evaluation process, including posing questions for researchers and reviewing the evidence report draft used by the panel.

In late October, the UPSTF panel met with consumer interest groups, including retired persons lobby AARP and the Consumers Union, to obtain input on how to frame recommendations that was once reserved for patient advocates.

The 2009 UPSTF mammogram guidelines were based on the panel's assessment of new research that showed most women over 40 face a 3% risk of dying from breast cancer if they have not been screened. Beginning mammogram screening at age 50 and following up every other year reduced that risk to 2.3%, compared with 2.2% risk starting at age 40. The panel feels that an extra decade of screening could result in harm such as unnecessary biopsies and procedure, the possible treatment of non-deadly cancers and radiation. The task force also notes that women in their forties are also more likely to receive false positive results.

The American Cancer Society (ACS) questioned the evidence, noting that the UPSTF focused on gold-standard clinical trials but weeded out newer observational studies that showed better results. "Screening is not perfect and it's not error-free, but the question is... do you take protective measures against the unlikely probability that you develop cancer... or do you take your chances?" noted Robert Smith, director of cancer screening at the ACS. Many healthcare analysts note that calculation still appears to be guiding doctors, either out of concern of missing an early diagnosis of disease or fear of lawsuits.

Although the PSA blood test itself is noninvasive, data reviewed by the UPSTF found that 90% of men in the U.S. who tested positive would receive further evaluation or treatment. Out of 1,000 men treated, five would die, 70 would have serious complications and 200 to 300 would be impotent or incontinent. Given the possibility of false positives in the screening and the fact that prostate cancer can take many years to progress and show symptoms, the question becomes whether those risks are greater than the risk of doing nothing.

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