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Congress undermines public trust by overriding mammography guidelines, authors say

In December, Congress required health insurers to follow breast cancer screening guidelines from 2002 rather than two more recent ones.

House Minority Leader Nancy Pelosi speaking at a news conference following the House vote on the Omnibus bill on Dec. 18.
REUTERS/Yuri Gripas

Last December, Congress slipped into its $1.15 trillion spending bill a measure that “undermines women’s rights to make informed decisions based on the best scientific evidence,” according to a commentary published recently in the Journal of the American Medical Association (JAMA).

That measure requires health insurers to follow the U.S. Preventative Services Task Force’s (USPSTF) breast cancer screening guidelines from 2002 rather than the task force’s two more recent ones, including its latest, which was issued just a few weeks ago.

The 2002 USPSTF guidelines recommended that average-risk women undergo mammography screening every one to two years beginning at age 40. After an exhaustive examination of the most recent scientific evidence, the task force updated their guidelines in 2009 and again this year to recommend that biannual screenings start later, at age 50.

“Essentially, Congress is requiring health insurers to ignore modern scientific assessments and instead use 14-year-old guidance,” write Dr. Kenneth Lin, a family medicine physician at Georgetown University, and Lawrence Gostin, a law professor at the same institution, in the JAMA commentary.

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That action has important ramifications that go beyond the issue of breast cancer screening, they add, for it also weakens the public’s trust in the value of evidence-based science.

Political backlash

Some background: One of the requirements of the Affordable Care Act (ACA), which was passed by Congress late in 2009 and was signed into law by President Barack Obama in 2010, is that private insurance plans must provide “first-dollar” coverage (no co-payments, coinsurance or deductibles) for any preventive service that receives an “A” or “B” grade from the USPSTF. (Those grades mean there’s a “high certainty” that the service’s net benefit for patients is “moderate” or “substantial.”)

Created in 1984, the USPSTF is an independent panel of experts with backgrounds in prevention and evidence-based medicine. They volunteer to assess the best evidence on various preventive services, and then make clinical recommendations regarding those services. Those recommendations are published in peer-reviewed journals (and on the USPSTF’s website), and are periodically updated.

In 2009, the USPSTF gave only a C grade to mammography screening for women aged 40 to 49 who are at average risk of developing breast cancer. This recommendation caused an instant and sometimes vicious backlash from medical groups, such as the American College of Radiology and the Medical Imaging and Technology Alliance, as well as from a few women’s health organizations.

The USPSTF’s updated guidelines were widely (and angrily) misinterpreted, however. Many people believed the task force was saying that women under the age of 50 should be denied access to mammography screening.

“A C grade is commonly misunderstood,” explain Lin and Gostlin. “It does not advise against screening, but rather it indicates moderate certainty that there is small population-level benefit. Clinicians should discuss C-rated services with patients using an individualized assessment of the patients’ risk factors and preference.”

And although insurers do not have to offer “first-dollar” coverage for a C-graded service, that was never really going to be the case with mammography.

As Lin and Gostlin point out, “Importantly, irrespective of USPSTF recommendations, most insurers have offered mammography coverage for women aged 40 through 49 years.”

Wrongly framed

One reason for all the controversy was that the USPSTF guidelines were framed by critics as a form of health-care rationing.

“Yet the Task Force uses a rigorous scientific methodology focusing on net health benefits and does not take economic cost into account,” the two Georgetown professors explain.

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Furthermore, the USPSTF is not alone in its interpretation of the evidence regarding mammography screening.  In Great Britain, for example, the National Health Service currently recommends that average-risk women be screened every three years starting at age 50 . And late last year, the American Cancer Society, shifted its recommended starting date for routine mammography from 40 to 45

“By declining to acknowledge scientific progress, Congress may do more harm than good to women’s health,” write Lin and Gostin. 

There is also a real risk, they add, that Congress may soon begin to erode the Task Force’s independence.

“The House’s version of 2016 omnibus spending bill (which was not included in the final legislation) would have denied funding for any future USPSTF mammography recommendation,” they explain. “Some members of Congress have gone further, proposing to alter the Task Force’s composition to include ‘stakeholders from the medical products manufacturing community.’”

Political second-guessing

So far, the USPSTF has withstood the pressures on its independence and scientific integrity, but will they be able to continue doing so in the future? 

Yes — if the public demands that Congress stop second-guessing the task force’s independent experts.

“When Congress required [the government] to link insurance coverage policy to outdated public health guidance, it was making a scientific judgment for which it is distinctly unqualified,” write Lin and Gostlin. “In effect, legislators implicity concluded that a rigorous assessment of numerous research studies during the past 14 years is not relevant to women’s health today.”

“Congress’s paternalistic response to USPSTF mammography screening recommendations vividly illuminates the social costs of politically mandated care,” they add. “Rather than benefiting women, political interference with science can discourage shared decision making, increase harms from screening, and foster public doubt about the value and integrity of science.”

FMI:  The commentary was published online in JAMA on Jan. 18, where it can be read in full.