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

TO THE EDITOR:

The USPSTF (1), regarded by many medical professionals as a premier source of information on preventive services (2), was blind-sided by the recent controversy regarding its recommendation against routine screening mammography for asymptomatic women younger than 50 years. Although the evidence-based panel prides itself on being independent of advocacy groups or managed care organizations, the controversy can be better understood if we consider the sociopolitical context of women's health and health care reform. Historically, women have had substantially less access to some of the major diagnostic and therapeutic interventions than men (3), were more likely to delay or forgo necessary medical care, and expressed more concerns about the quality of health care they received (4). The panel's recommendations may have prompted many to perceive, correctly or incorrectly, that the guidelines were a setback in the promotion of women's health.

In the midst of discussions on health care reform, the public's response may also reflect its skepticism of scientists' claim of value neutrality in evidence-based medicine and their social authority based therein. After all, even if scientific evidence is the most important factor in the panel's recommendation, choosing which conditions create a large enough burden of suffering on society to warrant the USPSTF's investigation is partly a value judgment (5). Because the USPSTF's ratings influence insurance coverage of various preventive services, the public's flat-out rejection of the panel's conclusion may be a result of its distrust in the social authority of expert opinion, confusion about the panel's decision-making process, and concern about how rationing and funding priorities are determined by these experts.

In responding to accusations that its recommendations were politically and economically driven, the USPSTF adamantly denied any financial considerations. Instead of convincing the public of its neutral stance, the USPSTF may have inadvertently perpetuated the impression that financial considerations in health care are never legitimate. As the country continues its debate on health care reform, the USPSTF and government officials may want to use this controversy as a new opportunity to facilitate more informed and responsible discussions among citizens regarding the planning and funding of health care programs. Rather than simply denying that economic or social context plays any role in scientific review, it may be more useful for the USPSTF to clearly explain what values were part of the consideration, how such values were chosen, and why such values were appropriate in determining its guidelines.

Anita Ho, PhD

University of British Columbia

Vancouver, British Columbia V6T 1Z4, Canada