Wednesday, December 2, 2009

The Politicization of Breast Cancer Screening

I just returned from a hearing of the House Energy and Commerce Committee's health subcommittee on the U.S. Preventive Services Task Force (USPSTF) breast cancer screening guidelines. Donna Sweet, MD, MACP, a general internist and HIV/AIDS specialist from Wichita, Kansas, testified on ACP's behalf. Dr. Sweet is a past chair of the ACP Board of Regents and a member of the College's Clinical Efficacy Assessment Subcommittee (CEAS), which has responsibility for developing the ACP's evidence-based clinical guidelines.

The first several hours of the hearing--and much of the grilling from the subcommittee members--were concentrated at chair and vice chair of the U.S. Preventive Task Force. The Task Force witnesses agreed that they could have done a better job in communicating the revised screening recommendations to the public but stood their ground on the evidence behind the recommendations. The USPSTF witnesses also made the point that breast cancer screening recommendations were voted on and approved late last year, before the Obama administration took office, so the politics of health reform had no role in their deliberations.

This didn't stop the politicians, though, from introducing politics into the USPSTF's recommendations. The headline from Reuter's says it all: "U.S. debate over mammograms splits along party lines."

Who knew that there was a Republican and Democratic view on the value of breast cancer screening? But in today's hyper-partisan and polarized politics, there is no issue that won't be used to divide the voters. Republicans argued that the USPSTF's recommendations were driven by a desire to cut costs - a charge that the USPSTF's witnesses steadfastly denied. (Fact check: the Agency for Health Care Research and Quality website specifically states that "economic costs" are never a consideration in the USPSTF's recommendations.) Republicans also argued that the House and Senate health reform bills would prohibit health insurers from offering prevention benefits that have not received an A or B evidence rating from the USPSTF, ultimately leading to U.K-style rationing. Democrats argued that the recommendations from the USPSTF would set a floor - not a limit - on the preventive services that insurers would have to cover. Both sides accused the other of mis-representing the truth.

ACP's own reading of the bills is that the Task Force's recommendations would improve access to evidence-based preventive services by establishing a floor, not a ceiling on benefits. On this point, ACP, the American Cancer Society, the National Breast Cancer Coalition, and the Susan Susan G. Komen for the Cure Advocacy Alliance all were in agreement.

Why did ACP wade into this fight? Well, for one thing, the USPSTF recommendations were published in our own Annals of Internal Medicine website. For another, in 2007, ACP issued its own guideline on screening mammography for women between the ages of 40 and 49, which recommended that clinicians and patients conduct an individualized risk assessment, discuss the risks and benefits of mammograms for this age group, and make their own judgment. But the biggest reason is that ACP believes that the politicization of evidence-based medicine is not in the public's interest.

This is what Dr. Sweet had to say:

"One lesson is that the public is ill-served when assessments of clinical effectiveness are politicized. For clinicians and patients alike to have confidence in the evidence, we need to know that it has been developed through a process that is independent of political pressure.
...Politicization [of evidence-based assessments], if left unchallenged ... could result in politically-driven changes so that future evaluations are influenced by political or stakeholder interests - instead of science."

Harold Pollack, writing in The New Republic blog, gives ACP high marks for its advocacy. Calling ACP "one of America's most respected medical organizations," he goes on to say this about ACP's stand against the politicization of evidence-based research:

"In its own wonky way, within an often-disheartening health policy debate, that's Change We Can Believe In."

Today's question: What do you think about the ACP's stand on the politicization of evidence-based clinical research?


Jerry M said...

I don’t feel that this debate is primarily political but rather true concern about the unintended consequences of a study that can be used to limit access to medical services. Interpretation of screening data is extremely difficult with biases almost impossible to correct for. It is ironic that the mammography study came out when it did because of the health bill and the intense advocacy involved with breast cancer.
It is beginning to look as though any opposition to provisions of the bill are interpreted by ACP as political or a lie. This concerns me greatly..
I am leery of a 2000 page bill that increases what they pay doctors but severely cuts total spending on Medicare. The claim is that only “unnecessary” medical care will be eliminated by reducing fraud and abuse, using a best practices commission, bundling, economic credentialing, etc.,but no meaningful tort reform. To me it simply means reducing what we will be allowed to do for anyone over 65.
The elderly of America who have contributed to this program all of their working lives do not deserve having their funds diverted to people who contributed nothing. They deserve better.

Harrison said...

Relative to evidence as a driving force for clinical decisions politics is intruding into the realm of the market.
The market has in the past and continues to drive research focus and interpretation of research. When evidence is lacking, the market steps in. When evidence can be used, the market steps in. Now the market is giving way to politics.
The federal budget deficit drives some of this debate.
But votes and sympathetic constituencies and fear also drive some of the debate.

The ACP has to be a constant and consistent voice of reason.
When evidence is good it should defend it.
The ACP is right to defend the positions of the USPSTF in this case.


Robert J. Sobel, M.D. said...

If we are to continue to let independent research and clinical care co-exist, we will need to make sure a government bureaucracy does not needlessly complicate things. Thank you for defending the process you have consistently let us see evolve over the years in Annals. The nuances of so many of our decisions seem to leave room for the emotional reactions that become entrenched. It is clear from our patients that they want clinical judgement to superceed rigid guidelines enforced via incentive systems. I will continue to advocate for the administrative simplicity of a well-adjusted fee-for-service system. This staff-model health system rhetoric remains disingenuous. Hospitals have leverage and self-interest. Independent practices are not the cost driveer here.

Our Senate is discussing and will come forth with a strange concoction. If we can bruise a few egos and remove the extra layers that make prose best never read, we could right the playing field and price regulate the commodities. Is there a voice from the other side to bring about said simplification? Would it come at the last stage? Does the President get to finally put his stamp on at the end?

Steve Lucas said...

"But in today's hyper-partisan and polarized politics, there is no issue that won't be used to divide the voters."

I, for one, am tired of watching a politician, any politician, use any question, as a basis for bashing the other party. Troubling is not only do they do this with a straight face, but with a great deal of sincerity.

The ACP has taken a more than reasonable and enlightened position on this issue and should continue the defense of evidence based medicine, not politically based medicine.

Steve Lucas

Rich Neubauer MD said...

We humans find it hard to receive information that is discordant with our preconceived notions. Excellent examples from the distant and not so distant past are how Galileo was treated in his day, how the discoverer of H. pylori was ridiculed for his scientific contribution, and how those who promoted the idea that thrombosis was a key component to myocardial infarction as opposed to merely progressive atherosclerosis were ridiculed by some.

ACP has done an excellent job in this case to once again take the high ground and point out that this is not about politics but rather about careful data analysis to make recommendations about areas of clinical decision making.

Donna Sweet's testimony was masterful, measured and even educational in pointing out how to best portray this information to patients.

The human psyche has not really evolved from the days when many would have promulgated torturing heretics for proposing the earth to be round rather than flat. That the U.S. debate over mammograms should split along party lines is testimony to that.