Local, State, Federal

Assessing the Impact of the USPSTF Mammography Recommendations

It has been several months since the US Preventive Services Task Force (USPSTF) issued its controversial recommendations to raise the mammography screening age for most women from 40 to age 50. The reactions to the recommendations have been overwhelmingly negative, causing confusion among women and physicians, as well as politicians currently drafting health care reform legislation. However, it may be too soon to tell whether the USPSTF has opened the door to fewer women having fewer mammography screenings and ultimately affecting breast cancer survival rates.

Carol Lee, MD, FACR

Carol Lee, MD, FACR, is chair of the Breast Imaging Commission of the American College of Radiology (ACR) and attending radiologist, Memorial Sloan Kettering Cancer Center, New York. Although it appears on the surface that breast cancer screening will continue as before, Lee is unsure whether the USPSTF recommendations will eventually change the state of mammography as radiologists now know it.

“It’s a done deal,” Lee said, “Now we just have to see how it affects—or does not affect—mammography utilization and mammography reimbursement in this country. We just have to leave it at that. There’s not much else we can do at this point.”

The Political Hot Potato

Since the release of the recommendations, the ACR has issued many statements and responses to the outcry from women’s groups, politicians, and radiologists.

Legislators opposed to a public option being included in pending health care reform legislation have used the USPSTF recommendations as an example of government rationing of health care.

In response to that accusation, health care reform supporters led by Senator Barbara Mikulski (D-Md) have authored an amendment that specifically excludes mammo-graphy from being denied coverage if the woman is aged 40. That amendment has passed.

In addition, Senator Tom Harkin of Iowa, chair of the Senate Health, Education, Labor, and Pensions Committee, will be holding hearings to investigate the Task Force’s recommendations and the reasoning behind them. (Lee’s reading of the recommendations only finds mentions of improved “efficiency” of breast cancer screening, but she notes there is nothing that directly mentions that the recommendations are based on reducing costs.)

Finally, shortly after the recommendation fallout, Health and Human Services Secretary Kathleen Sebelius issued a statement affirming that USPSTF’s recommendations will have no impact on government policy and should not impact private insurers’ policies.

For now, however, nothing has changed in terms of coverage and policy on a national level. “As things stand right now, there’s a legislative mandate to ensure continued coverage under Federal government-sponsored plans such as Medicare and Medicaid. So there’s no change in that regard,” said Lee.

However, Lee points out that the Federal government’s support of the old recommendations has not prevented California’s Department of Public Health from changing its “Every Woman Counts” screening program for low-income women. The new policy mirrors the USPSTF’s new recommendations. Like many states, California’s budget is in crisis, and consequently, the change is seen as being economically based and inspired by the USPSTF.

Meanwhile, the American Cancer Society, the National Breast Cancer Foundation, and the ACR continue to advise regular, annual mammograms beginning at age 40.

Insurers, Primary Care Physicians, and the Future

The ACR has issued a press release asking physicians and the community to alert the ACR should any coverage change for mammography screening.

For now, radiologists can do nothing but wait to see what actually transpires from these recommendations. The notion of limited mammograms is now in the minds of primary physicians, insurers, and women who may or may not now seek screening every year after 40. Some women, fearing the pain of an unnecessary biopsy, may now wait until age 50, as the USPSTF recommends.

Lee said, “I don’t know what’s going to happen to volumes or referrals for mammograms. The trend in general has been for mammography utilization to decline. It’s declined in the recent past. I’m not sure why and nobody’s sure why, so it will be interesting to see if that decline continues or if it actually accelerates.”

Part of the USPSTF’s stated reasoning behind its recommendations was to reduce the pain and stress of unnecessary biopsies. Lee acknowledges that there are false positives that do lead to pain, stress, and unnecessary biopsies, but says that it is protocols and screening technology that should be—and are—being developed to address that issue. Raising the screening age to 50 or recommending fewer mammograms before 50 is not a solution to reducing cancer rates.

Asked about her advice to women who may be confused by the two mammography screening recommendations, Lee said, “If a woman asks me whether she should have a mammogram, my answer is that it’s been shown that mammography decreases death rates from breast cancer. It’s not perfect. It’s going to miss some cancers, and it’s going to find things that turn out not to be cancer. It may find some cancers that would never have gone on to threaten the person’s life, but when you weigh everything, it saves lives. I think that’s the bottom line.”

—Tor Valenza