Friday, January 15, 2010

The Defense of the Breast Cancer Recommendation

In JAMA, Dr Woolf makes his defense of the breast cancer screening recommendations of last fall stating:

ON NOVEMBER 16, 2009, THE US PREVENTIVE Services Task Force (USPSTF) released breast cancer screening recommendations, sparking controversy and intense media coverage. As portrayed by the media, the government had recommended against mammography for women aged 40 to 49 years, despite evidence that mammograms saved lives, and against women examining their breasts, the method by which most breast cancers are detected.

The recommendation drew fire. The problem is that the USPSTF was lacking in any sensitivity to what it was saying and how it said it. Take for the example the statement made by Woolf that they make no recommendations to insurance companies:

The USPSTF does not advise insurers. Since its inception, the USPSTF has focused on the question of whether preventive services improve health outcomes. The recommendations are derived by weighing benefits and harms to patients; costs and coverage issues are ignored. Clinicians, not policy makers, have always been the target audience.

How naive. He seems to be saying that they just say things and that what they say has no effect on the world. Clearly insurance companies can and will and have used the recommendations of this group and others to deny coverage. One has to live as a hermit in a cave not to know and recognize this. This single statement is in itself in my opinion discrediting.

Then the good doctor continues with the following:

Concern about harms is not trivial. Breast cancer is an age dependent disease; the benefit from screening increases with age. Among women aged 39 to 49 years, at least 1000 women must undergo periodic mammography to prevent 1 breast cancer death.1 Younger women also face increased risk of harms from screening, such as false-positive findings, biopsies, anxiety, and over diagnosis and treatment of latent disease.

One death may be one death too many. How many skin exams does it take to save one malignant melanoma death. Many, indeed, but it is that one time, that single instant, when the physician and the patient see what appears to be the start of a deadly growth, and then one must act instantly, delaying not even a week. The breast has the same set of issues.

He ends the above by saying that the harms (sic) are false findings, anxiety, and even a biopsy. To any physician after years of practice, the patient in your office is often filled with anxiety about what ever brought them there. It may be the teenager with the swollen lymph nodes or the elderly woman and her rectal bleeding, and even the middle aged man with gastritis, or the heart attack.

Anxiety and biopsies are matters of course. Performing fifty biopsies on pigmented lesions to save one life is well worth the cost and the discomfort. Even more so regarding breast cancer. The statement is in my opinion a value judgment, not a clinical statement.

He continue with several suggestions. They are:

First, scientific panels on controversial topics should gauge public sensibilities and communicate clearly when releasing recommendations. Scientists are wise to banish politics from their recommendations but are unwise not to plan for the political reception that awaits them.

Second, society needs a forum for intelligent public debate, a challenge in today’s media environment. The USPSTF tempest was fomented by the 24-hour news cycle, talk shows, and blogs that ridiculed the panel and disseminated erroneous claims, conspiracy theories, and rhetoric contributed by reporters, pundits, politicians, and callers. Perversely, the information age now makes it easy to trample facts with misinformation, “breaking” news, and talking points. This helps politicians, the media, and special interests earn votes, profits, and ratings but does harm to public enlightenment.

The second observation is interesting. It appears as if the good doctor has been hiding in the 19th century, at best. Has he ever heard of twitter? Half of this very blog's readers now come from twitter. The people connected to the Internet get and disseminate information at a tremendous rate. The people do not just listen to cable news, they go after the facts directly.

It thus was not the 24 hour news shows, it was the fact that people can and do get the information from the web, specifically the facts which the USPSTP was forced to remove, and read if for themselves.

What then compounded the problem was the almost total arrogance, in my opinion, of how this group then presented it. For example, by stating implicitly in my opinion that insurance companies will take no notice, amidst the most intense debate on health care, was totally unreasonable, and then deciding in their recommendations implicitly and even explicitly what was good for women, namely lessening anxiety while increasing mortality, was equally unreasonable. The logic, in my opinion, was quite clumsy, to say the least.

It is reminiscent of the grey haired OBGYN in the starched white coat looking at a women and saying "Now dear, just take a few of these pills every day and things will be all right." Those days are long gone.

The good doctor ends with the following:

Third, if today’s public sphere cannot escape these influences, the responsible recourse is to preserve independent bodies that can deliberate with clarity, insulated from interference. The public should safeguard these efforts, even if they disagree with the findings, but too often the reverse occurs, as the hostility to the USPSTF illustrates. Independent panels should not be intimidated for political reasons, but they are.

He appears to be quite defensive that anyone, especially the public, should question his judgment. Yet it is just that, a judgment, and people did not like it. It was presented poorly, explained even more poorly, and one of the members of the Committee appeared as if she were a deer in the head lights and she was not capable of articulating any reasonable explanation as to what had been recommended.

This article is an example of what is wrong with this committee. not what is wrong with the recommendation It is also an example of how in today's information rich world one must follow Osler, "If all else fails, listen to the patient!"