US Preventive Services Task Force and Breast Cancer Screening

Abstract

THE US PREVENTIVE SERVICES TASK FORCE (USPSTF) was established more than 2 decades ago as an independent panel of experts in primary care and preventive care with the mandate to conduct rigorous, unbiased assessments of the scientific evidence for the effectiveness of clinical preventive services. The task force uses state-of-the-art methods and explicit criteria for assessing the available evidence and issues recommendations for prevention interventions along with the strength of evidence supporting those recommendations, thereby enabling research on prevention to be translated into clinical practice. Using their usual rigorous methods, including a commissioned systematic review of recent studies and modeling studies of various screening strategies, the USPSTF recently updated the 2002 recommendation statement on screening for breast cancer. Based on thorough evaluation of the available evidence of benefits and harms, the 2009 recommendation statement was updated as follows: the USPSTF recommended “against routine screening mammography in women aged 40 to 49 years,” but emphasized that “the decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.” The task force also recommended biennial screening mammography for women aged 50 to 74 years, extending the recommendation beyond the 2002 statement to include women aged 70 to 74 years, but concluded that the current evidence is insufficient to assess additional benefits and harms of screening mammography for women aged 75 years and older. In addition, the task force concluded that the current evidence is insufficient to assess additional benefits and harms of clinical breast examination beyond screening mammography in women aged 40 years or older and also recommended against teaching women how to perform breast self-examination. Despite careful assessment of the science behind the updated guidelines, the USPSTF recommendation statement for breast cancer screening, particularly the recommendation regarding routine mammography screening for women aged 40 to 49 years, immediately generated controversy among physicians, disagreement from professional associations such as the American Cancer Society and the American College of Radiology, and outrage from some breast cancer survivors and advocacy groups. The term “routine” apparently was a key word meant to clarify the recommendation, but the meaning was lost or misinterpreted by many. Among other issues, there were concerns that the guidelines would result in insurers denying coverage for mammography screening for some patients and allegations that the guidelines were politically motivated, held up as an example of the health care rationing that purportedly will occur after health system reform is enacted. Perhaps the various reactions of the public and concerns about the task force can be better understood by considering that the issue of screening for breast cancer enters “the murky area between mathematics and psychology.” A person’s beliefs and behaviors do not necessarily follow scientific evidence, especially if the perception is that life is at stake. In this issue of JAMA, 4 Commentaries provide insights into important aspects of the USPSTF recommendations and the implications for physicians and patients. Woolf, a former member of the USPSTF and an author of the 2002 recommendations, describes the misperceptions about the task force and clarifies the misinterpretations of the breast cancer screening guidelines yet cautions that “the mammography controversy, now 2 decades old, is not going away.” Woloshin and Schwartz discuss the importance of understanding the benefits and harms of mammography screening for breast cancer, including false-positive screening tests and overdiagnosis, and provide a useful quantitative summary of key data points that could help foster understanding and aid in decision making about mammography screening. Murphy, a physician-scientist and breast cancer survivor, acknowledges the limitations of mammography as a screening test but emphasizes the strong desire of women to achieve an early diagnosis of breast cancer and high-