Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer FREE

TO THE EDITOR:

Although the USPSTF breast cancer screening recommendations (1) are meant to provide guidance to clinicians and their patients, these and other USPSTF recommendations are released in a public health arena and may have unintended or unforeseen effects on public health. Unfortunately, current practices of the USPSTF seem not to take this into account.

For example, I believe that the recommendation against clinicians teaching breast self-examination (BSE) was related to a particular form of BSE, and that the recommendation, as communicated, may have unintended negative consequences. First, it assumes that most such education occurs through interaction with clinicians. Although the recommendation is only to clinicians, the USPSTF does not explain how it may or may not apply to other settings or persons (for example, health educators and public health departments). Nor does the lack of specificity regarding this recommendation account for the possibility that women may be taught how to be more aware of BSEs and how to conduct them for other reasons, such as finding cysts.

In addition, the language of the recommendations indicates that the only concern is for clinicians and their patients. However, the recommendations are also widely disseminated in the media to women who do not have health care coverage or clinicians to interact with on a regular basis—or if they do, only in emergency situations. The recommendations as perceived by these populations could have the unintended effect of not only decreasing the use of breast cancer detection services (including public health services) but also conveying the impression that these issues are not important for persons without regular health care. Furthermore, there is little consideration about the effect on other health behaviors at a time when the entire health community is urging people to be more aware of and to take a more active role in their health and health behaviors, as well as to shift toward prevention and early intervention before tertiary intervention is required.

Although the USPSTF properly tries to address 1 clinical issue at a time, it operates in an arena in which clinical and public health concerns and effects naturally intermingle and in which persons apply what they have learned about one health behavior to another. As much as the USPSTF may assume otherwise, the recommendations are disseminated not only to clinicians but also to persons who might be patients but in reality have little regular interaction with clinicians and to nonclinicians who regularly address the same or similar health concerns with the patients of others.

Richard Yoast, MA, PhD

American Medical Association

Chicago, IL 60654