Failure to Communicate: Setting the Record Straight on Mammographies

Since it was first convened by the U.S. Public Health Service in 1984, the U.S. Preventive Services Task Force (USPSTF) has pretty much performed its duties—conducting "impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications"—outside of the public limelight.

Who really ever heard of the task force outside of the medical community?

Two weeks ago, that all changed with the release of breast cancer screening guidelines—and the ensuing confusion about what they actually meant.

At a Dec. 2 hearing on Capitol Hill, the top two officials with the task force, which is now a part of the Agency for Healthcare Research and Quality, came to the realization that it's not just sufficient to come up with guidelines, but to communicate those guidelines very clearly to the public at large.

It could be argued that the timing of the release of the breast cancer screening guidelines occurred at the wrong time—just days after the House healthcare reform bill (HR 3962) was passed—and a new discussion, right or wrong, was emerging over the 24/7 news cycles about the possibility of how the government could ration healthcare.

"We voted on these recommendations long before the last presidential election. The timing of the release of the findings last month was determined not by us—but by the publication schedule of the medical research journal, which peer-reviewed our work," testified Bruce Calonge, MD, MPH, the task force chair and chief medical officer with the Colorado Department of Public Health and Environment in Denver.

But in the land of sound bytes, the top line of the new screening guidelines caught attention: "The USPSTF recommends against routine screening mammography in women aged 40 to 49 years."

Then the statement went on to say: "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 graded the recommendation with the grade of "C"—meaning the task force graded the strength of the evidence as "no recommendation for or against" (as opposed to "A" for strongly recommends or "B" recommends.) Then many—including legislators on Capitol Hill—began to worry if that could mean insurers might drop coverage.

To refocus the argument and address the concerns, representatives of the task force found themselves in front of the House Energy and Commerce Health Subcommittee to say their earlier recommendations were "poorly worded"—leading the public to think they were suggesting screenings were unneeded for patients in their 40s.

To clarify, Diana Petitti, MD, MPH, the USPSTF vice chair, acknowledged that the initial communication was not very good. "The task force acknowledges that the language used to describe its 'C grade' recommendations about breast cancer screening for women 40 to 49 did not say what the task force meant to say. The task force communication was poor."

She also noted the harms and benefits that the panel weighed in making its evaluations—which sometimes might not seem that clear-cut. While benefits "are easy to communicate," the harms are somewhat harder to understand—such as false positives.

"No matter how the concept of screening is explained, a positive mammogram means cancer until cancer is proven not to exist. For some women who have a positive test, the time between a positive test and an answer is mercifully short. For other women, follow-up includes additional tests . . . and anxiety and psychological distress."

It's with these findings, she said, that "mammography starting at 40 should not be automatic." Instead, the task force recommends that "women in their 40s [should] decide on an age to begin screening that is based on conversation with their doctor as an individual."

Now that’s something to communicate to everybody.