Mammography and comparative effectiveness research: What do you do when you don't like it?

April 1, 2010

Healthcare reform may be upon and one of its main goals is cost control.

Wrong! Comparative effectiveness research is a win-win only if it is what you want to do. However, based on the recent US Protective Services Task Force (USPSTF) recommendations for mammography screening, we have to ask ourselves: "What do we do when we want to do something that is not deemed to be the best by CER?"

In November 2009, the USPSTF, an independent nongovernmental panel of 16 medical and scientific experts evaluating the value of screening tests, said that mammography should not be performed routinely until age 50 and then only every 2 years until age 75. They also said that there was not enough evidence to recommend breast self-examination and clinical breast examinations. The panel concluded that screening for breast cancer before age 50 is harmful and suggested that we are actually hurting women by screening as they had previously recommended in 2002. They stated that the false-positive results from these screenings and the resulting biopsies did not improve a woman's odds of surviving breast cancer and were therefore unacceptable.

We have to ask ourselves why everyone is so upset. The USPSTF recommendations are the essence of quality medicine: Look at the data and change what we are doing when it is not supported by the evidence. We should be thrilled that an independent group has reviewed data and given us a way to decrease harm to our patients and decrease costs. So why are most people unhappy with the new recommendations?

This conflict between what we know and what we are being told by CER is at the heart of the future of healthcare. Everyone knows of a woman in her 40s or younger who has had breast cancer detected by a mammogram, self-breast examination, or clinical breast examination. We all think of these practices as being lifesaving. However, we know that many women have been sent for repeat mammograms, breast ultrasounds, or breast biopsies because the original mammogram was not definitive, and everyone is happy when no malignancy is found. So why is there conflict? Are professional and lay groups unhappy because they don't believe the data, or are there other reasons that may be influencing their objections?

My own opinion is that the rapidity and vehemence of the reaction by professional and lay groups against the USPSTF recommendations indicate a lack of critical evaluation of the data the panel used to formulate their recommendations. The response appears to be based on anecdote, emotion, and possibly self-interest. Could it be that the immediate strong negativity to the recommendations may be because of reluctance to change, difficulty in breaking old habits, the perception that the healthcare system is more interested in saving money than in a patient's well-being, or personal financial issues related to the loss of reimbursement for tests and procedures? I don't know, but we must accept that CER may result in changes in care that affect many interest groups who don't want to change what they have been doing.

How do we, as responsible professionals, react to this type of change in medicine?

I suggest that we respond to it as we do to any other type of data. Before new recommendations come out, they always should be fully peer reviewed. Proposed recommendations and the rationale behind them need to be published. They have to be critically reviewed by clinicians responsible for the care of patients in this particular area. Their methods and data must be evaluated, and if flaws in the proposed recommendations are present, they should be openly discussed. Only after this process is completed should final recommendations be adopted. If the data and conclusions are appropriate, we should adopt them as professionals, even if our self-interest or our anecdotal data tell us we should not.

I believe that that is what the professional societies should have done with the new USPSTF recommendations.

I suspect the USPSTF report on mammography will be one of many recommendations being made about healthcare resource use in the near future. If we as professionals want to maintain our credibility in determining the healthcare systems of the future, we must develop systematic mechanisms for accepting or rejecting the results of CER based on critical evaluation, rather than emotion and self-interest. If we don't do this, outside agencies will undoubtedly make changes for us. This is not what I think we want to have as the future of medicine.