Controversy over recent breast cancer screening guidelines discussed

American College of PhysiciansDec 4 2009

ACP also considers release of mammography guidelines by USPSTF before subcommittee on Health of House Energy and Commerce Committee

The controversy over recent breast cancer screening guidelines offers an opportunity to engage individual patients in an informed discussion of the importance of evidence-based clinical efficacy assessments in contributing to better care decisions, Donna Sweet, MD, MACP today told the Subcommittee on Health of the House Energy and Commerce Committee. Dr. Sweet testified at a hearing, Breast Cancer Screening Recommendations, on behalf of the American College of Physicians (ACP).

Dr. Sweet spoke as a physician who has been involved in internal medicine for more than 20 years as a teacher, administrator and provider of care to patients. She is a former chair of the ACP's Board of Regents. Her perspective on evidence-based assessments comes not just from her patient-care experiences, but also from her role as a member of ACP's Clinical Efficacy Assessment Subcommittee (CEAS). The CEAS's role is to oversee the development of ACP's evidence-based guidelines that make recommendations that ultimately improve the practice of medicine.

In her testimony, Dr. Sweet addressed three key questions:

1. Does ACP have an opinion on the breast cancer screening guidelines issued by the Task Force, or have its own clinical guidelines on mammography?
2. How are evidence-based clinical guidelines, such as those on breast cancer screening, used by clinicians in practice to engage their patients in shared decision-making to provide a personalized diagnosis and treatment plan?
3. What can be learned from the controversy over the breast cancer screening guidelines to guide future policy-making?

She explained that ACP is one of many partner organizations of the United States Preventive Services Task Force (USPSTF). While ACP, as a matter of policy, does not comment on the guidelines of other organizations, she did speak to ACP's own guideline on screening mammography. Developed by ACP's CEAS and approved in 2007 by the ACP Board of Regents, the guideline recommends that for women between the ages of 40 and 49, clinicians should:

• Periodically perform individualized assessment of risk for breast cancer to help guide decisions about screening mammography.
• Inform women in this age group about the potential benefits and harms of screening mammography.
• Base screening mammography decisions on benefits and harms of screening as well as a woman's preferences and breast cancer risk profile.

"I believe that my role is not to dictate to my patients what they should do," Dr. Sweet said in how she incorporates ACPs recommendations into her own practice. "Instead, it is to use my professional training and skills to help my patients weigh the evidence so that they can make their own decisions on what is best for them, taking into account their individual risk factors, values, and preferences. This demands that I personalize the presentation of information on the efficacy of different cancer interventions, be straightforward with my patients on the limitations and ambiguity of such evidence, and discuss with them their own preferences."

Addressing lessons learned from the controversy over the recent breast screening guidelines, Dr. Sweet noted that the public is ill-served when assessments of clinical effectiveness are politicized. For clinicians and patients alike to have confidence in the evidence, physicians need to know that it has been developed through a process that is independent of political pressure.

"ACP is concerned that such politicization, if left unchallenged, could lead to efforts to eliminate the Task Force, cut its funding, or result in politically-driven changes so that future evaluations are influenced by political or stakeholder interests-instead of science," Dr. Sweet emphasized. "We would be concerned that this would also lead to political interference over other federally-funded entities involved in evidence-based research."

The controversy over the mammography guidelines, Dr. Sweet noted, illustrates the importance of communicating information on evidence-based reviews to the public in a way that facilitates an understanding of how such reviews are conducted and how they are intended to support, not supplant, individual decision-making by patients and their clinicians.

Her patients, she said, have the right to know that the evidence that she discusses with them comes from respected, independent and credible clinicians and other scientists who are protected from political and stakeholder pressure.

"ACP urges Congress, the administration, and patient and physician advocacy groups to respect and support the importance of protecting evidence-based research by respected scientists and clinicians from being used to score political points that do not serve the public's interest," Dr. Sweet concluded.