Critics of the U.S. Preventive Services Task Force's new recommendations on breast cancer screening said late last week that they fear damage may already have been done to the 20-year effort to increase the rates of annual mammography among women age 40 and older.
Critics pan screenings report
Mammogram policy could boost mortality rates
Despite assurance from HHS Secretary Kathleen Sebelius that the CMS would not be changing its mammogram coverage policy, critics say that the task force's recommendations will lead to fewer mammograms and potentially higher breast-cancer mortality rates.
Sebelius' statement “has value in terms of Medicare reimbursement, but it still concerns us that the recommendations will confuse patients and providers,” said Dave Fisher, managing director of the Medical Imaging and Technology Alliance, an industry trade and lobby group. “I'm hopeful that insurance companies and other providers are willing to take her position to heart.”
In a statement last week, Sebelius reiterated that the task force—established in 1984 by Congress and charged with reviewing and issuing opinions on the effectiveness of preventive care—is an independent group of physicians and scientists and said “they do not set federal policy” or “determine what services are covered by the federal government.” Her announcement followed a firestorm of criticism by various groups that said they fear the recommendations could influence future reimbursement of mammography and discourage women from having annual screenings.
“I don't think anybody really knows at this point how these recommendations will translate into guidelines,” said Carol Lee, chairwoman of the American College of Radiology's Breast Imaging Commission. “The bottom line is we have a test we know works and they're saying it's not cost-effective. It's just unconscionable.”
Insurers spend between $3.3 billion and $5 billion annually to cover mammograms, according to the ACR.
The task force's advice counters long-standing guidelines for women age 40 and over to have annual mammograms. Instead, in an article published in the Nov. 17, 2009 issue of the Annals of Internal Medicine, the group, which is largely made up of primary-care physicians, suggested that women ages 40 to 49 with no family history or predisposition for breast cancer no longer undergo routine mammography.
The mammogram recommendations were drafted following a review and analysis of clinical trials on breast cancer screening and survival rates conducted between 2001 and 2008, according to the article. The task force also suggested women ages 50 to 74 only undergo mammograms every two years and said it found no clinical evidence that the test was beneficial to women over age 74. It also found no evidence that self-examination reduced mortality rates, and said physicians should stop advising women to conduct such exams.
While the group acknowledged that studies show mammography screening reduced breast cancer rates by 15% in women ages 39 to 49, it said false-positive results and overdiagnosis of existing breast cancers were more likely to occur in women under 50, and as a result they were more likely to undergo unnecessary and costly biopsies and additional imaging tests.
Such references to cost have prompted a number of critics to suggest that the task force's recommendations are a step toward rationing healthcare and causing a further reduction of imaging reimbursement.
The screening recommendations are “anti-technology and anti-innovation,” said Tim Trysla, executive director of the Access to Medical Imaging Coalition, a group representing the interests of radiologists and imaging-device makers. “You can't say these tests are preventative and then turn around and embrace these policies.”
Susan Pisano, spokeswoman for the trade and lobby group America's Health Insurance Plans, said her organization doesn't anticipate the recommendations changing private insurers' current reimbursement policies. “Women who believe that they want to go ahead and do screening before 50, it's our understanding that they will continue to be covered,” she said.
Peter Bye, a managing director and analyst covering devicemakers with the investment bank Jefferies & Co., made a similar assessment of the recommendations' potential effect. “We continue to believe that breast cancer screening remains relatively safe from significant reimbursement pressure due to its political relevance,” Bye wrote in a report issued the day after the task force's recommendations were released. “Most states have laws which provide access to annual mammography screening exams, and we do not believe that the (task force's) new guidelines will impact the ability of women to access these exams in the near term.”
Despite such reassurances, a significant number of providers and professional medical organizations have reiterated their support of current guidelines advising women to begin routine annual mammography at age 40. “We released two statements to our members and encouraged them to review with their patients the benefits of screening,” said Hal Lawrence, vice president of practice activities for the American College of Obstetricians and Gynecologists.
For its part, the ACR acknowledged it is pleased Sebelius has affirmed the CMS' commitment to continue covering mammography. But the organization also expressed some continued concerns. “We ask that the secretary officially ask the task force to rescind their mammography recommendations in order to avoid confusion as healthcare reform moves forward,” said ACR Chairman James Thrall in a written statement.
Meanwhile, the ACOG released its own set of relaxed guidelines for women's health, recommending last week that a woman's first Pap smear be delayed until age 21. The group also said that women younger than 30 should undergo a cervical screening once every two years instead of annually, and those age 30 and older get rescreened once every three years.
“The tradition of doing a Pap test every year has not been supported by recent scientific evidence,” said Alan Waxman, a physician at the University of New Mexico School of Medicine in Albuquerque who helped write the document developed by the ACOG, in a statement. “A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs and avoids unnecessary interventions that could be harmful,” he said.
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