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ONLINE EXCLUSIVE: Evidence-Based Medicine Curveball


 

Even simple practice guidelines can be controversial. Guidelines are not created or implemented in a vacuum; they must be interpreted within a complex—and sometimes conflicting—milieu of medical, social, economic, and political forces.

This past November the U.S. Preventive Services Task Force, a federally funded, scientific advisory panel, released a 2009 update to its 2002 recommendations on breast cancer screening. The updated guideline said women in their 40s with an average risk for breast cancer do not need annual mammograms to screen for the disease, and older women at average risk of developing breast cancer need screening only once every two years.

The new guideline sparked disagreement among physicians, and a heated political debate as to whether the recommendation amounted to government-mandated, guideline-based, economically motivated healthcare rationing.

Some groups, including the American Cancer Society, said that mammograms have been proven to save lives by spotting tumors early on when they are most easily treated, and said they would stick by their current guideline to start annual mammogram screening at age 40. The Radiological Society of North America cited studies showing mammography of women in their 40s saves lives, and said about 20% of all breast cancer deaths in our country occur in women in their 40s.

The timing of the task force's recommendation was unfortunate (some lawmakers said it was calculated), as it was announced in the midst of the heated congressional healthcare reform debate. Although the new guideline would save a portion of the more than $5 billion spent on mammography in the U.S. each year, the task force said politics played no part in its recommendation, and that cost savings were never considered in its discussions. The task force acknowledged potential benefits of earlier testing, but attempted to balance those benefits with the potential harms of unnecessary radiation exposure, biopsies, overdiagnosis and overtreatment, and anxiety to women who get false positive results, which the panel said occurs in 10 percent of mammograms.

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