Point of View

A screening change based on evidence

November 18, 2009 

— The U.S. Preventive Services Task Force gained considerable attention with the release of its new recommendations against the current standard practices of breast cancer screening. No routine breast cancer screening for women under age 50? Decreasing the frequency of screenings to once every two years for women ages 50-74? These differ from current recommendations of the American Cancer Society.

We rely on these expert professional bodies to give us advice based upon the best available evidence. New confirmative data from population-based mathematical modeling studies and careful combination of all existing research trials have prompted the Preventive Services Task Force, or USPSTF, to recommend these changes.

With these revisions, the USPSTF is fulfilling its obligation to put society first, to bring forward information which benefits the greater population. Anecdotes about young women who, through early use of mammography or self breast exams, discover they have cancer and manage to live longer lives or be cured are important; these women are examples of educated consumers of health care. The individual stories do not change the evidence that shows that for women in their 40s with average risk of disease, yearly mammography will not mean differences in outcomes at the public level.

Based upon my own review of the data, these revised recommendations make sense. So what now?

Health care professionals and patients probably feel like something is being taken away and not being replaced by anything better. Let's look at it this way: contemporary data suggest that the current practice isn't actually as beneficial as it could or should be, so any sense of loss is perceived, not actual. As more information and newer techniques become available, the process of review and replacement will begin again.

We saw this with hormone replacement therapy (HRT) several years ago. When the data came out challenging its safety and discouraging its use, many women felt like we were losing a therapy that helped us overcome the realities of menopause. As a society, we had to learn how to integrate that new information into our lives. Women in particular had to weigh our individual risks versus benefits with regard to HRT, together with advice from our doctors, and decide what to do. We must continue the discourse with our doctors, and need to be persistent about yearly follow up for all forms of health care and prevention, including breast cancer.

Physicians must make some quick adjustments. The USPSTF is asking us to change our systems and the ways we communicate with our patients. We will very likely observe an increase in both our patients' anxiety and the number of anxious conversations we have with them, and we are asking ourselves, "How am I going to be able to handle all those conversations? Address the new recommendations?"

We need to learn from experience. For example, health care professionals figured out long ago how to teach older men with early-stage prostate cancer that it was something that was very unlikely to limit their lives. The most important part was teaching them how to deal with having cancer in their bodies. This intervention was more a matter of communication, not a medicine-based intervention.

Health care providers and consumers now must harmonize the recommendations of different professional bodies. The guidelines will be divergent in one way or another; they always have been. A review of the care practices in Australia and some European countries leads me to believe that most guidelines will ultimately align themselves with the USPSTF's new recommendations.

Importantly, these guidelines are for women of average risk. They do not apply to women who are at high risk, such as those with a known genetic mutation predisposing them to breast cancer. Again, it comes back to individual doctors and patients working together to sort this out in terms of what makes the most sense for each woman.

We need to educate the public to do what works: don't smoke, eat healthfully, exercise, actively participate in our care. Smoking rates are on the rise lately. This is distressing, since smoking prevention offers well-demonstrated personal and public health benefits.

Physicians know that evidence-based medicine directs best practice. I applaud the USPSTF for its courage. This was not an easy step to take, but it is one that is supported by the evidence. The medical community must rely on professional bodies like the USPSTF to embrace change when new information emerges. We trust that as better screening and new knowledge come along, the professional bodies will update their advice again.

Dr. Amy Abernethy is an oncologist at Duke University Medical Center and associate director of population sciences at the Duke.

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