Nananda F. Col, MD, MPP, MPH; Moritz H. Hansen, MD; Baruch Fischhoff, PhD; Steven G. Pauker, MD
Potential Conflicts of Interest: None disclosed.
Col NF, Hansen MH, Fischhoff B, Pauker SG. Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer. Ann Intern Med. 2010;152:542. doi: 10.7326/0003-4819-152-8-201004200-00206
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Published: Ann Intern Med. 2010;152(8):542.
TO THE EDITOR:
The recommendation statement by the USPSTF (1) sensibly concludes that the decision about mammography should be an individual one, reflecting the patient's values regarding specific benefits and harms. However, the USPSTF did little to enable women to understand these risks and benefits and did not help them to make sound choices about screening. For women in their 40s, the USPSTF considered a 55% chance of a false-positive result (2) to prevent 1 breast cancer death for every 1900 women screened to be unacceptable. Curiously, they reached the opposite conclusion for women in their 50s, in whom “only” a 46% chance of a false-positive result to prevent 1 breast cancer death for 1300 women screened is acceptable. The difference between 1 in 1300 and 1 in 1900 (0.053% vs. 0.077%) is so small that it is difficult to imagine a woman for whom it would matter, which makes this an odd policy distinction. This is a classic “close call” or “toss-up,” and either choice should be acceptable (3).
Other factors to consider are the psychological stress of treatment and the reassurance of having done everything possible by being screened. Women are entitled to know the chances that mammography will uncover a treatable cancer and the chances that screening will lead to useless, risky treatment. Reasonable women could make different choices, depending on how they feel about these risks and benefits. Rather than having numbers dictate their decision, women should decide how high of a risk they want to take for how much potential benefit.
The public debate sadly veered to whether the USPSTF served the interests of bureaucrats, eager to ration medical care, and insurance companies, eager to deny coverage. But history is repeating itself. A dozen years ago, a National Institutes of Health consensus panel (4) created similar guidelines and also suggested that women in their 40s decide for themselves about screening. Public reaction was similar: widespread concern that the recommendations were driven by health care costs, not science (5). We should have learned that the motivation behind guidelines is easily misconstrued and that the public does not trust expert panels.
Patients cannot make informed medical decisions without adequate information that is clearly communicated. The difference between rationing health care and rational health care lies in who makes the decision. If policymakers or insurers limit the availability of tests, it feels like rationing. However, if informed patients choose to forgo tests that are less effective, it becomes rational decision making.
Nananda F. Col, MD, MPP, MPH
Moritz H. Hansen, MD
Maine Medical Center
Portland, ME 04101
Baruch Fischhoff, PhD
Carnegie Mellon University
Pittsburgh, PA 15213
Steven G. Pauker, MD
Tufts University School of Medicine
Boston, MA 02111
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