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New mammogram guidelines cause another political uproar

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By Dan Eggen and Rob Stein
Washington Post Staff Writer
Wednesday, November 18, 2009

In 1997, a federal committee of medical experts recommended against routine mammograms for women in their 40s, sparking a political uproar that led to congressional hearings and a unanimous Senate vote challenging the findings.

Now, 12 years later, a similar drama is playing out around a different federal medical panel, which this week recommended against routine mammograms for women younger than 50, saying it is not worth subjecting some patients to unnecessary biopsies, radiation and stress.

The independent panel, the U.S. Preventive Services Task Force, also recommended against teaching women to do regular self-exams and concluded that there is insufficient evidence to recommend that doctors do exams.

The findings underscore a decades-long debate in the medical community about the benefits and risks of routine breast cancer screening for younger women. The conclusions also plunge the nonpartisan, nonpolitical advisory panel into the middle of a strident Washington discussion about health care, which has included allegations from Republicans that the Democrats' proposed reforms would lead to reduced care for patients.

Rep. Frank Pallone Jr. (D-N.J.) announced Tuesday that his House health subcommittee will hold hearings on the mammogram issue next month. Other lawmakers from both parties suggested that the task force had been swayed by insurance companies that stand to save money if fewer screenings are performed.

"We can't allow the insurance industry to continue to drive health-care decisions," said Rep. Debbie Wasserman Schultz (D-Fla.), who said earlier this year that she had undergone treatment for breast cancer.

The recommendations also garnered harsh criticism from powerful medical groups including the American Cancer Society -- which says it will continue to recommend regular mammograms for women older than 40 -- and the Access to Medical Imaging Coalition, which warned that the findings would "turn back the clock on the war on breast cancer."

Many patient advocacy groups and breast cancer experts, however, praised the decision, arguing that politics have too often interfered with science when it comes to mammograms. Maryann Napoli, associate director of the Center for Medical Consumers, said breast cancer screening is frequently "used by politicians as a way to say they are for women," whether or not the underlying policy makes sense.

Conflicting studies

Both the research and the policy decisions surrounding tests for early breast cancer have had a topsy-turvy history, leading to confusion among patients and caregivers alike.

For example, when a National Institutes of Health panel declared in 1997 that routine mammograms for women in their 40s may not be worth the risks, the Senate convened hearings and voted 98 to 0 to urge the National Cancer Advisory Board to endorse routine screenings for that age group, a recommendation that was eventually adopted.

In addition, the panel that issued this week's guidelines came down on the other side of the issue under different membership in 2002. The task force, a 16-member group of independent experts put together by the Department of Health and Human Services, concluded that the evidence at the time tilted slightly in favor of using routine mammograms for women in their 40s.

The immediate impact of the newest guidelines is unclear. Forty-nine states require insurers to cover screenings for women 40 and older; Medicare also pays for the procedure. The task force said women with a family history of breast cancer or other risk factors should have routine screenings.

But critics note that under legislation pending in Congress, the panel's guidelines could be used to set standards for what insurance companies would be required to cover. And although the latest research was started long before the most recent health-care debate began, the timing of Monday's announcement led many opponents to speculate that the two are related.

"The only conclusion I can come to is it's economically motivated," said Carol H. Lee, who chairs the American College of Radiology's breast-imaging commission. "In this climate, when we are all paying attention to how we can decrease the cost of health care, in my opinion that's the primary motivation."

Defending the panel

But Ned Calonge, who chairs the 16-member panel, defended the recommendations and denied that cost or the debate over health-care reform played any role in the decision. "Cost just isn't a consideration when the task force deliberates," said Calonge, who is also the chief medical officer for the Colorado Department of Public Health and Environment. Twelve of the task force members were seated during the Bush administration, and the remaining four were chosen before President George W. Bush left office, he said.

To conduct the review, Heidi D. Nelson of the Oregon Health & Science University in Portland led an analysis of data from more than 40 studies, including a new British study involving more than 160,000 women and data collected from more than 600,000 women in the United States.

In addition, the task force commissioned an unusual study led by Jeanne S. Mandelblatt of the Georgetown Lombardi Comprehensive Cancer Center and funded by the National Cancer Institute that involved six separate teams of researchers analyzing the risks and benefits of 20 screening strategies.

"I think anytime you use science to kind of fundamentally change what people are used to, I think it's a difficult thing to grapple with," Calonge said of the new guidelines.


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