Critical Thinking Not Fear Based

konakat

Sorry Otter -- sometimes it's hard not to respond to such things.  I'll stick to the purpose of the thread.

otter

That's okay.  I'm not the Thread Police.  Really, I'm not.  I was just feeling grouchy about all the political stuff.  And, yes, I know how hard it is to resist the bait.

Hugs...  sleep well.

otter 

konakat

I know -- I was grouchy on another thread -- we all get grouchy.  You sleep well too Otter.

Elizabeth

xox

Blundin2005

Good morning all,

Otter and Elizabeth (konakat) hope that you are both sleeping well. I woke just an hour ago, made my coffee and loaded some software before coming here.  I plan to spend the day outdoors just to change the air.

I woke thinking about the issues surrounding these Guidelines. People here zeroed in on various aspects.  We are not without our own bias this is certain and we each built our comments on assumptions.

My mind keeps returning to medical research first.  If my memory serves, the abstract of a scientific paper states first the assumptions made (void of preconceived ideas even though they exist), the math models and values applied to the assumptions, a description of the course of study then the result and conclusion on the part of the researcher(s).  

For the purpose of this discussion, my bias for review of the facts presented is to eliminate finance, politics, culture, socioeconomic, psychological and other external influence from the equation of the medical evidence first.  

Then one at a time, address the external factors in terms of priority--like triage in the ER.  This is not to diminish the importance of the external factors, only to position them where they can do no harm.

I thought too about a long standing rule that doctors not treat their own family.  This is because they would loose objectivity which is imperative to "first do no harm".  In many ways, we are the doctors in this discussion and it is our family who is affected.  We are not objective.

This is not to say that we need to be--or that our opinions are not valuable.  Our opinions are like the adrenaline pumping through the veins of a doctor trying to save a patient whose life is in their hands.  We work hard to be heard.  Less we forget the battles won here when the medical community was deaf to hear us.  Nonetheless, we can't treat our own family and trust that our judgement validates the outcomes.

I thought to compile all of the assumptions that each of us made on this thread and see what picture they framed.  The problem is that my time is limited.   

I'm reminded too of the story Frankenstein and how it was used in school as a point of healthy discussion about how medical decisions impact society over time, e.g. how far to go, hysterical mobs, tender hearts of monsters, etc.  Historical and sometimes literary perspectives are helpful. 

My comment about the task force.  Do I remember many primary care physicians on the task force--gyn too who I often consider women's 'primary care' docs.  I need to assume that they functioned as practicing physicians before to accept the role of administrative trust keepers and thus have experience of patient care.  Then I thought that if this is true, then they tended to the everyday life of patients who live the broad base of what specialists can focus, eg. work, family, quality of life.  I'm grateful for specialist but I also think there can be a disconnect of information.  The specialist tells us their up to date research and findings and this is then taken in by us , the patient, who then needs the primary care physician to translate the medical jargon into 'how will this affect my life' jargon.  Then--ultimately--the decision is ours to make.  We often want someone else to make that decision for us when it gets hard....and it doesn't get harder than life and death decisions.  This is reasonable given our diagnosis that we share, but not feasible.

We'll keep mining for information to help us make the best choices.  We'll keep sharing what we know to each other because we are sisters.  We'll even keep trying to change the world around us.  I believe that's our best traits.

Best wishes to all as always,

Marilyn 

Anonymous

Bottom line is - If someone creates a totally safe, reasonably priced, breast cancer screening device or machine, that is proven effective and recognized by insurance companies, then they would have the right to address the mammo issue.

It's simple...I learned this early on in the business world: if you're going to suggest change/reform, you better have a strong, proof positive alternative, or keep your mouth shut.

IMO - until the above is accomplished - leave the guidelines as is. Any woman who chooses NOT to have mammos should simply not comply. PERIOD.

otter

Something has been bothering me about my ambivalence.  I think Laura's post was the answer I've been trying to find.

It's one thing for a group of medical researchers to gather and analyze the results of studies on a topic and write a review article.  That group would be Nelson, et al., the authors of one of the studies commissioned by the USPSTF: "Screening for Breast Cancer: An Update for the USPSTF (http://www.ahrq.gov/clinic/uspstf09/breastcancer/brcanup.htm).  Their role was to provide the USPSTF with an "update" on the effectiveness of BC screening methods. 

The "Nelson" group produced a traditional "review article", except for two things.  1) The topic they researched and the questions they addressed were assigned to them by the USPSTF and the AHRQ.  Even if they wanted to, they couldn't come up with different questions or disregard those they were given.  And, 2) their work was done on behalf of the USPSTF.  The "Nelson" group undoubtedly knew their findings would be used by the USPSTF in updating the screening guidelines.  But, conscientious scientists are not supposed to let emotions or politics influence the design of their studies or their interpretation of the results.

[BTW, there was a second study commissioned by the USPSTF that was also published with the new guidelines and the Nelson paper.  That other study was basically a computer simulation (mathematical modeling) of many different combinations of mammogram scheduling, to see the effect those different schedules would have on mortality rate from BC.  It wasn't a clinical study or a literature review -- it was strictly a statistical prediction. It was also used by the USPSTF in developing their new guidelines, but I haven't been able to slog through that other paper yet.]

So, the USPSTF commissioned those two studies, and used the results to come up with their recommendations.  I think that's where the problems arose.  Personally, I am now leaning toward "blaming" all this on the USPSTF after all.  They are not "scientists" -- they're a panel of doctors and public health (preventive healthcare) experts that has no "consensus" expertise in any specific area of medicine.  They depend on the findings of the studies commissioned from the medical research-folks.  The USPSTF couldn't figure this out for themselves.  But, ... again, IMHO ... the USPSTF can make decisions about how they're going to apply the evidence they're given -- what is "good" evidence, which evidence is "inadequate", what threshold will they use to decide if a "harm" is significant or trivial.

Even though much of the evidence the USPSTF used was objective (numbers, levels of statistical significance), they also used a lot of subjective information.  How did they decide whether a woman's "anxiety" from a BIRADS-3 mammogram report was more harmful than the "anxiety" she might suffer from not having a mammogram every year?  What made them think a negative biopsy was a greater "harm" than not having screening mammograms at all? What criteria did they use to decide that a 15% reduction in BC mortality (the "relative benefit" from mammographic screening of women in their 40's) was not enough of a benefit?  They said, "There is modest certainty that the net benefit is small."  By whose standards was the evidence "modest" and the benefit "small"?  I've read the definitions of their "levels of certainty"; and IMHO, they are very, very fuzzy.

So... I think the USPSTF had the power and authority to interpret the findings of the reviews any way they wanted, and apply them however they wished.  After all, they weren't "doing" the scientific research--they were writing recommendations. 

For example, the USPSTF could have said, "Okay, there really isn't very strong evidence supporting routine mammography on women in their 40's; but the evidence we have does show a 15% relative benefit.  And, we've been recommending regular mammograms in those women for the past, oh, 7 years.  So, although we are beginning to question the need for those regular screening mammograms, and those mammograms do cause some degree of "harm", we don't yet recommend that they be discontinued.  The evidence against them (the "harm" of pain and anxiety and "unnecessary" biopsies) is soft and subjective; and we've been unable to factor it into a mathematical formula.  We think women ought to consult their doctors and come up with a strategy that best fits their personal situation, including their personal risk of developing BC, the benefit that mammography provides them personally (i.e., dependent on breast density), and their own comfort with risk-taking.  But, until we have strong evidence that mammography in women in their 40's causes harm and/or does not save lives, we are not going to change our previous guidelines -- we are not going to recommend against routine mammography in those women."

I've been watching football games this weekend.  When an official makes a call that one of the coaches questions, the coach can issue a "challenge" to get the call reviewed.  The "replay official" can also ask for a review, if the call seemed controversial.  Everybody takes time out, and some guys in a dark room review all the available evidence (instant replay film) to see what the call should have been.  Then they make a ruling about the call -- should it be upheld or overturned?  The standard of proof is what's important, though:  The call cannot be overturned unless there is "incontrovertible evidence" that the original call was incorrect.  If the replay film is from the wrong angle or doesn't show the play clearly enough, and the accuracy of the call is still unclear, the original call stands.  Once the call is made, it can't be overturned unless the evidence against it is "incontrovertible".  The assumption is that there was enough evidence to make the call in the first place, so it's presumed to be correct unless/until proven otherwise.

If it's good enough for NFL and college football, it's good enough for healthcare guidelines.  If a recommendation has been in force since the last review and it was supported by adequate evidence then, it should take "incontrovertible evidence" to overturn the recommendation.  And, I'm beginning to think there was not "incontrovertible evidence" in the case of the BC screening guidelines.

Here's an article from Reuters that makes that point:  http://www.reuters.com/article/newsOne/idUKTRE5AJ3GO20091120

otter 

AnnNYC

Excellent points, Otter.

Also, a poster called "DukeMom2" made a great point on the sign-the-petition thread: I won't quote her exactly until I get an okay by PM from her, but basically she asked whether the USPSTF even considered the potential benefit of biopsies resulting from abnormal mammogram that are "benign" but reveal atypical ductal hyperplasia, in the process removing the ADH cells, alerting the woman and her doctor that she is at greater risk and needs closer monitoring, and (my thought) perhaps leading to initiation of preventive tamoxifen or raloxifene in an at-risk woman.

None of the three papers mentioned this at all, and I do think it's a possible benefit from mammography screening -- which the USPSTF authors (including Nelson et al) probably actually consigned to the "harm" column in their analysis.

otter

Ann, I've been wondering about those "negative" biopsy results, too.  A close friend of mine has had 4 biopsies, and I know at least 2 of them were ADH.  As it turns out, her risk of BC is actually higher than mine is now, and much higher than mine was before I found out I had BC.  Her high-risk status is due, in part, to her biopsy findings, and also some family Hx and other factors.  She is now consulting an oncologist about "preventive measures" she can take.

If she hadn't had those "negative" biopsies, she would be under the impression that her risk of developing BC is much lower than it actually is.

otter 

brcagrl

I've been deeply disappointed in the sensationalism surrounding the guidelines and rampant misinformation/interpretation. I have read this report and it has been mistranslated and taken out of context. Even Dr. Weiss, for whom I have great respect, has unfortunately fanned these flames.

First, breast self exam (BSE) is NOT being discouraged. The report states that physicians should not include teaching BSE as part of medical consultations and check ups. Seriously, how many women were taught BSE by their doctors?  I was taught by a nurse outside the examination room. I teach it at health fairs where people usually don't want to know. I strongly recommend that the current breastcancer.org survey be corrected so as not to misinform women about what these guidelines suggested.

Second, with the exception of Utah, every state in the U.S. has a mandate - on the state level - that requires insurance companies to cover mammography screenings from age 40 and upward. That cannot and will not be changed except through any legislative changes on the state level so a petiton to anyone other than your state insurance boards and state legislators is a futile exercise. I would expect breastcancer.org to be aware of this.

Here is what concerns me. Some very important information is being overlooked by the manipulation of this report and all the uneducated reactions being printed and broadcast by the media. There is a serious truth being ignored.  Mammography is all we have as a large population screening tool. Mammography is not flawless and very little progress has been made in understanding what cancers will or will not progress into life threatening disease.  The concept of cancer not being deadly is very hard to grasp when 40,000 women still die of this disease on an annual basis. It seems absurd to those of us who had invasive breast cancers.

Mammography does not save lives. We all know that treatment saves lives and not every cancer that is detected early responds to treatment. Not all DCIS progresses to invasive cancer yet we are removing breasts, and introducing radiation and chemotherapy to women who never needed it. Don't we want to see this change and for research to determine how to successfully identify and treat what is being imaged? The image only tells a small part of the story, not nearly all of it.

So few women who qualify for coverage are not bothering to be screened and those in high risk populations have no access to screening. Those who need diagnostic screening (mostly younger women) can't gain access to it.

I truly hope we can understand the message that has been given.  We need better tools and methods. We aren't making the progress we thought we were and the death rate is still too high. SEER data doesn't even require reporting for breast cancer recurrence.  Thousands of women are living with breast cancer who have had recurrences and the U.S. does not require that to be reported. There is so much more to this picture than incidence and mortality.

In the meantime, please keep doing those breast (or chest wall) exams, go for your mamograms (diagnostic or screening) and keep those doctor appointments. No one is telling you not to! Unfortunately, this is still all we've got right now but we can do better than this. Let's send that message and move the process forward, otherwise, we're just standing still in a dark room.

And for the sake of full disclosure, I was diagnosed almost 10 years ago with very aggressive breast cancer detected by a BSE just a few weeks after her mammogram showed what appeared to be yet another fatty cyst.  Had I placed all my faith in mammography, my story would no doubt be different and I would not be typing this like so many others whose voices we aren't hearing in this discourse.  I'm a woman of faith but I don't want "faith based" medicine.

pitanga

Hi,

This discussion is fascinating. I´m sorry to chime in so late but I have a couple of questions that seem pertinent. Since as BRCA girl points out, mammos tend to be less useful in screening younger women because of the breast density issue, I don´t understand why in the US they dont supplement mammo screening with ultrasound for those hard-to-read cases. In Brazil ultrasound is a routine part of gynecological checkups. It is safe and quite cheap.

When I was first dx'd (in Brazil), I was 39 and all that you could see on the mammo was some calcifications. The ultrasound is what showed the mass. And they used the ultrasound to guide the biopsy. I know I have read lots of posts by women on these boards whose tumors also didnt show on mammo but did when they followed up with ultrasound. So why isnt it a routine part of screening?

Also, while I understand the task force's logic about all those biopsies of lumps that turn out to be benign (though I´m not sure I agree with the conclusion not to screen), I am very confused about the concern over negative health consequences of extra mammos. Have there been studies showing that the extra radiation from mammos can cause health problems?

Some posters have written that the amount of radiation you get from a short plane flight is greater than what you get from a mammo. I have also heard this claim before, but never any numbers. If it is true that mammos can cause cancer further down the road and that flying exposes us to even more potentially dangerous radiation, maybe the task force should also make some pronouncements about all the unnecessary flying people do in this day and age....

Lisa 

(did a little editing for clarity) 

brcagrl

There is something I find very promising that was announced in a preass release last week but it was buried by the mammography guidelines reaction.

There is a new system called the Softvue system developed by the Karmanos Cancer Institute. It uses no compression and utilized ultrasound. It is fast and more specific than mammography.I think something like this could improve the percentage of women adhering to screening. Discomfort is an issue and no one enjoys getting a mammogram.

Let's just hope and encourage large randomized control trials comparing systems like this with   mammography as a screening tool. Affordability is one issue that concerns me because our healthcare systems are struggling and have made large investments in mammography systems.

Gitane

Does anyone else feel manipulated?  I wonder why a task force guideline that was created 18 months ago is being debated so publicly and passionately immediately before the U.S. senate debate on healthcare reform.

Do we have a window of opportunity here?  If nothing else, this debate brings into focus the weaknesses in current policies and screening methods.  As others here have so eloquently stated, we are witnessing a struggle for money and control in our health care system.  The women of the U.S. are the most impacted by breast cancer.  I am saddened to read the pleas to at least maintain the status quo when it is so painfully obvious to all that improved screening is needed.

I hope we, and our leaders, will continue this discussion long after the heat of it has subsided.  I also hope the voices of the women throughout the world will lead to necessary changes. 

swimangel72

Thanks for the links and explanations Otter - you always explain things so clearly and RATIONALLY to me - bc.org is blessed you are still on board!

otter

I realize this might not be the proper thread for the article I'm about to give you, but I found it amazingly on-target. It's from the Huffington Post, which isn't one of my usual hangouts.  This columnist, though, is arguing the same thing Laura and others here have been saying.  See what you think about it: "What Happens When The Anger Subsides? -- The New Breast Cancer Guidelines."

otter 

Blundin2005

Good morning all,

    Otter, it is good to see that you rested well.  Among others, I look for your insightful posts every morning.

   I read the article that you posted and agree that much of what Dr. Reardon wrote was “on target” and on topic.  If I understood correctly, she layered onto the medical research presented by the task force in the guidelines, the  projected outcomes that external influences impart to the decision process: financial, socioeconomic, and political. 

   I found this the most important statement that she made:

   “We should be concerned that public outcry will lessen and this research actually will be used to alter the current guidelines. If so, insurers will wait until things have gotten quieter and they will remove coverage for routine screening mammography for women below the age of fifty and perhaps other relevant testing as well.”

   Our national attention and energy is diverted now from the healthcare reform debate to one specific hot button issue—cancer.  Whether the diversion is by design or not, the effect is the same.  The problem is how well the patient will fare in the end….as yet not measured.

   My intuition strongly suggests that the insurance and pharmaceutical interests to retain power and position will out-stripe the efforts to bring critical thinking to the delivery of public health care policy.  There were many valid suggestions made relative to the mammogram issue among the women here on the boards that mitigate the negative aspects of the Guidelines effectively.  That fact tells me the possibility strongly exists with the policy makers as well.

  My DH commented this morning that what strikes him and others here (EU) the most about the system in the US is the drama and misinformation that is created around the issue of health that they believe is central to their human rights.  When and how did we loose those protections in the US?

  As so many others already said, this vital issue now is front and center on stage.  In that fact, I now can see the wisdom in the BC.org response to hold it there.  Perhaps these are the tactics that are required to be heard over the drone of misinformation.  Negotiating with insurance companies is as effective as negotiating with bankers for their bonuses.  Times change.

  I hope in the end it is the patient who is served by the efforts and not the false market of cost and reimbursement created and driven by profit incentives.

Best wishes to all as always,

Marilyn 

RunswithScissors

I read the bio's of the Task Force board members, and the criticisms that they lack the qualifications to make such recommendations seem unfounded. While these folks are not onc's, some are specialists in biometrics and statistics, some in disease prevention, creating public policy  etc. 

They seemed to form a capable well, rounded group  suited to the task of doing a meta-analysis - and I can't attack them on the grounds that they were not qualified.   However, I think the number of studies they included should have been more broad.   In addition, their inability to clearly communicate their findings was appalling. 

The timing is clearly politically motivated and the hyperbole from the opposition has muddied the discussion further. 

When I was first dx, I discovered a little trick about medical info gathering-I found that most

doctors were more inclined to discuss the pros of any given test or treatment than the cons. (Especially if there was no alternative to it). They  tend to praise our current practices, compare it as so much better than what we had x number of years ago, etc. 

I found that when you  read about  up and coming technologies, you are much more likely to learn those cons. When docs were comparing current protocol to something new in the pipeline -  they did not hold back discussing the shortcomings of how we do things now.  

It made me aware of what a good job the medical community does of the "united front" game.  Of course there are always the few who step out and refuse to go along - but for the most part, they feign extraordinary consensus.

This outburst completely wiped out that smoke screen.  I dismayed and glad at the same time. 

Seven11

I have mixed feelings too.  I think the main problem is that we have been completely oversold the idea that mammograms save lives.  We need to focus on curing and prevention.  We should be angry that so many millions of dollars have been spent on mammograms for young women when they are clearly not working.  

I'd also like to call for some sanity on reading these guidelines.  They call for an end to ROUTINE mammograms before age 50.  They are encouraging a conversation between the doctor and the patient.

 I too am disturbed by this organizations knee-jerk response.

I am sickened by people who are using this recommendation to forward their fear-mongering, death panel ideas.  

RunswithScissors

 *****

klfh wrote:

I am sickened by people who are using this recommendation to forward their fear-mongering, death panel ideas. 

********

I know what you mean, the whole idea is so goofy - 

At some point in recent history, some group got together and created the current recommendation to begin screening at age 40.  

Where was the righteous indignation for women who get cancer at age 39 and younger? (especially considering the younger you are when dx, the more likely you are die)  Why weren't there protests about insurance death panels? Rationing? 

How can these folks argue that the guideline should stay as they are currently? They are fine accepting 40 as a cutoff date and "damning" anyone younger than that.  They arent' questioning  risk/benefit considerations for someone who is 39. 

What's the difference in the stats is you change the range from 39 to 49?  Or any other arbitrary number....  

AnnNYC

While I am fed up with the "death panel" and "rationing" hysteria too, I don't think it's correct to say everyone signing the petition lacks "righteous indignation for women who get cancer at age 39 and younger."  Quite the opposite, in fact.

Frankly, one of the things I find most distressing about the new guidelines is the way I fear it will "trickle down" to primary care physicians/ob-gyns.  Many of these docs in the U.S. already have the impression that a woman under 45 is "too young to have breast cancer."  I don't have a lot of faith in the general medical community being any more thoughtful about the new guidelines than the general public -- I fear the guidelines will reinforce a prevailing belief that younger women just aren't at risk, rather than that younger women need different and better screening methods.

AnnNYC

Oops, I said "fear" a lot in that previous post !!!  Well, then -- I "suspect" that the new guidelines may enforce a prevailing belief, etc...

Wonder if there has been a survey of beliefs about breast cancer held by primary care physicians/ob-gyns?  "You're too young to have cancer," "if it hurts, it's not cancer," etc.  I'm going to do a literature search.

Seems to me that one important public health/preventive services function would be to assess prevailing "received wisdom" in the general medical community, and direct educational efforts to correct mistaken beliefs...

RunswithScissors

AnnNYC-

I did not mean I disagree with all the arguments. I was referring to blatant hypocrisy of the politicos.  

Seven11

Ann, ditto.  I don't think all of the arguments are wrong, in fact I have my own mixed feelings about this.  Sadly, I am seeing widespread hysteria about this more than anything else. 

Margerie

I used my critical thinking skills to find the following:

The Current 2009 Members of the Task Force

Bruce Nedrow (Ned) Calonge, M.D., M.P.H. (Chair)- Associate Professor of Family Medicine and of Preventive Medicine and Biometrics at the University of Colorado Health Sciences Center

Diana B. Petitti, M.D., M.P.H. (Vice Chair)- Professor of Biomedical Informatics at the Fulton School of Engineering, at Arizona State University

Susan Curry, Ph.D- dean of the College of Public Health and distinguished professor of health management and policy at the University of Iowa

Allen J. Dietrich, M.D.- board-certified family physician, is a professor of community and family medicine at Dartmouth Medical School

Thomas G. DeWitt, M.D.- Professor of Pediatrics

Kimberly D. Gregory, M.D., M.P.H.- Director of Maternal-Fetal Medicine and Director of Women's Health Services Research at Cedars-Sinai Medical Center, Los Angeles, CA

David Grossman, M.D., M.P.H.- board-certified pediatrician

George Isham, M.D., M.S.- Medical Director and Chief Health Officer for HealthPartners, a large health care organization in Minnesota

Michael L. LeFevre, M.D., M.S.P.H.- Professor in the Department of Family and Community Medicine at the University of Missouri School of Medicine

Rosanne Leipzig, M.D., Ph.D.- board-certified internist and geriatrician


Lucy N. Marion, Ph.D., R.N.- family medicine/psychiatric nurse practioner


Joy Melnikow, M.D., M.P.H.- professor in the Department of Family and Community Medicine and associate director of the Center for Healthcare Policy and Research at the University of California Davis. She is currently a deputy editor of Medical Care, standing member of the health services organization and delivery study section at the National Institutes of Health


Bernadette Melnyk, Ph.D., R.N., C.P.N.P/N.P.P.- pediatric and psychiatric nurse practioner


Wanda Nicholson, M.D., M.P.H., M.B.A.- board-certified obstetrician-gynecologist and a perinatal epidemiologist

J. Sanford (Sandy) Schwartz, M.D.- board-certified internal medicine specialist

Timothy Wilt, M.D., M.P.H.- board-certified internal medicine specialist

For those keeping score that would add up to:

family medicine- 5
biomed informatics- 1
health management and policy (PhD)- 1
pediatrics- 2
ob/gyns- 2
internal medicine- 3
nurse pracitioners (family medicine/psychiatry/peds)- 2



oncologists- 0
radiologists- 0
breast cancer surgeons/specialsists- 0

I always say if something stinks, check your shoe. What stinkbomb I found is that numerous members of this 16-member panel are currently or have been directly involved with the HMO or health care industry.

This information came directly from USPSTF

Dr. George Isham, MD is the Chief Health Officer for a major health care provider, Health Partners. "Dr. Isham is responsible for quality, utilization management, health promotion and disease management, research, and health professionals' education at HealthPartners. He is active in strategic planning and policy issues. He is an experienced primary care clinician and was chair of the Institute of Medicine committee that produced the report, Priority Areas for National Action: Transforming Health Care Quality." (quote from USPSTF)

J. Sanford Schwartz, MD, is the past executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania. He's also on the Blue Cross and Blue Shield Medical Advisory Panel. He was also formerly the Editor of the American Journal of Managed Care

Diana B. Petitti, MD (the Vice Chair of this panel who said that these recommendation would have no effect on health insurance coverage) was a Senior Scientific Advisor for Health Policy and Medicine at Kaiser Permanente of Southern CA.

Joy Melnikow, M.D is a contributing member of the California Health Benefits Program Task Force for the University of California's Office of the President and associate medical director of Healthwise, Inc.



Hmmmmm...  if you were to assemble a health care/action committee to review and possibly revise breast cancer screening guidelines for the good citizens of the U.S.A., would you not want SOMEONE on this panel that has treated a breast cancer patient? Would you consult any of these people if you had, or suspected you had breast cancer?? Is it not a conflict of interest, or at least VERY bad taste, to have the health care industry represented (by some means) by at least 25% of this panel and breast cancer specialists make up 0%? And we are supposed to believe there is no motivation here except to better the health of American women overall?


I think this smells like &$#@!

RunswithScissors

Margerie,

I don't know what you do for a living , but would you be willing to limit your backround to  a one sentence resume? 

These folks have some pretty impressive and extensive credentials. 

The idea that they are not  biased by a specialty is the point - they are  supposed to be reviewing existing studies.  

Here are the qualifications required to be selected:

Qualification Requirements: The mission of the USPSTF is to produce
evidence-based recommendations on the appropriate screening,
counseling, and provision of preventive medication for asymptomatic
patients seen in the primary care setting. Therefore, in order to
qualify for the USPSTF, an applicant or nominee must demonstrate the
following:
1. Knowledge and experience in the critical evaluation of research
published in peer reviewed literature and in the methods of evidence
review;
2. Understanding and experience in the application of synthesized
evidence to clinical decision-making and/or policy;
3. Expertise in disease prevention and health promotion;
4. Ability to work collaboratively with peers; and,
5. Clinical expertise in the primary health care of children and/or
adults, and/or expertise in counseling and behavioral interventions for
primary care patients.
Some USPSTF members without primary health care clinical experience
may be selected based on their expertise in methodological issues such
as medical decision making, clinical epidemiology, behavioral medicine,
and health economics.
Consideration will be given to individuals who are recognized
nationally for scientific leadership within their field of expertise.
Applicants must have no substantial conflicts of interest that would
impair the scientific integrity of the work of the USPSTF including
financial, intellectual, or other conflicts. (http://edocket.access.gpo.gov/2008/E8-11191.htm)
 

Gitane

Margerie,  I found your post very interesting.  It does not surprise me that in the selection of the task force members, or any government advisory group for that matter, a certain slant is given to the results.  

TenderIsOurMight

Here is a list of the members of the 2002 USPSTF Mammogram Guidelines Task Force, taken directly from AHRQ (see link below):

Members of the Task Force

Members of the U.S. Preventive Services Task Force are Alfred O. Berg, M.D., M.P.H., Chair, USPSTF (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Janet D. Allan, Ph.D., R.N., C.S., Vice-chair, USPSTF (Dean and Professor, School of Nursing, University of Texas Health Science Center, San Antonio, TX); Paul S. Frame, M.D. (Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Charles J. Homer, M.D., M.P.H. (Executive Director, National Initiative for Children's Healthcare Quality, Boston, MA); Mark S. Johnson, M.D., M.P.H. (Associate Professor of Clinical Family Medicine and Chairman Department of Family Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ); Jonathan D. Klein, M.D., M.P.H. (Associate Professor of Pediatrics and of Community and Preventive Medicine, University of Rochester School of Medicine, Rochester, NY), Tracy A. Lieu, M.D., M.P.H. (Associate Professor, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, MA); Cynthia D. Mulrow, M.D., M.Sc. (Professor of Medicine, University of Texas Health Science Center, Audie L. Murphy Memorial Veterans Hospital, San Antonio, TX); C. Tracy Orleans, Ph.D. (Senior Scientist, The Robert Wood Johnson Foundation, Princeton, NJ); Jeffrey F. Peipert, M.D., M.P.H (Director of Research, Women and Infants' Hospital, Providence, RI); Nola J. Pender, Ph.D., R.N. (Professor and Associate Dean for Research, School of Nursing, University of Michigan, Ann Arbor, MI); Albert L. Siu, M.D., M.S.P.H (Professor of Medicine, Chief of Division of General Internal Medicine, and Medical Director of the Primary Care and Medical Services Care Center, Mount Sinai School of Medicine and The Mount Sinai Medical Center, New York, NY); Steven M. Teutsch, M.D., M.P.H. (Senior Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); Carolyn Westhoff, M.D., M.Sc. (Associate Professor of Obstetrics, Gynecology and Public Health, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY); and Steven H. Woolf, M.D., M.P.H. (Professor of Family Medicine, Department of Family Practice, Virginia Commonwealth University, Richmond, VA).

Contact the Task Force

Address correspondence to: Chair, U.S. Preventive Services Task Force; c/o Project Director, USPSTF; 540 Gaither Road; Rockville, MD 20850; E-mail: info@ahrq.gov.

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Available Products

This recommendation and rationale statement, plus complete information on which this statement is based, including evidence tables and references, are available on the USPSTF Web site at http://www.preventiveservices.ahrq.gov.

The summary of the evidence and the recommendation statement are also available in print by subscription to the Guide to Clinical Preventive Services, Third Edition: Periodic Updates.

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Current as of February 2002

http://www.ahrq.gov/clinic/3rduspstf/breastcancer/brcanrr.htm

Why would AHRQ twice omit breast cancer surgeons, breast specilty radiologists, and breast cancer treating oncologists when determining USPSTF guidelines on screening breast mammograms?

AnnNYC

The USPSTF is a single 12-member panel that addresses all questions assigned to them.  It seems the intent at the outset (in 1984) was to make them a panel whose focus was community health/family health/primary care (thus the inclusion of pediatricians and ob-gyns).  Each member has a 4-year term.  Every year, the panel's membership changes by one-fourth: 3 members reach the end of their 4-year terms, and 3 new members begin a 4-year term.

When the USPSTF is given an assignment, they then commission studies to be done by experts in the field they are reviewing, to provide the USPSTF with information.

I don't think this is a great set-up.  But that's how it has been done for every kind of guideline/recommendation they have addressed since 1984.

RunswithScissors

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TenderIsOur wrote:

 Why would AHRQ twice omit breast cancer surgeons, breast specilty radiologists, and breast cancer treating oncologists when determining USPSTF guidelines on screening breast mammograms?

******

The process for choosing who will be on the panel and why is explained at this link, which was provided just 2 posts prior to yours.

http://edocket.access.gpo.gov/2008/E8-11191.htm 

TenderIsOurMight

From 2002: http://www.annals.org/content/137/5_Part_1/347.abstract

• Clinical Guidelines

Breast Cancer Screening: A Summary of the Evidence for the U.S. Preventive Services Task Force

1. Linda L. Humphrey, MD, MPH;
2. Mark Helfand, MD, MS;
3. Benjamin K.S. Chan, MS; and
4. Steven H. Woolf, MD, MPH

+ Author Affiliations

1. From Oregon Health & Science University and Portland Veterans Affairs Medical Center, Portland, Oregon; and Medical College of Virginia, Virginia Commonwealth University, Fairfax, Virginia.

Abstract

Purpose: To synthesize new data on breast cancer screening for the U.S. Preventive Services Task Force.

Data Sources: MEDLINE; the Cochrane Controlled Trials Registry; and reference lists of reviews, editorials, and original studies.

Study Selection: Eight randomized, controlled trials of mammography and 2 trials evaluating breast self-examination were included. One hundred fifty-four publications of the results of these trials, as well as selected articles about the test characteristics and harms associated with screening, were examined.

Data Extraction: Predefined criteria were used to assess the quality of each study. Meta-analyses using a Bayesian random-effects model were conducted to provide summary relative risk estimates and credible intervals (CrIs) for the effectiveness of screening with mammography in reducing death from breast cancer.

Data Synthesis: For studies of fair quality or better, the summary relative risk was 0.84 (95% CrI, 0.77 to 0.91) and the number needed to screen to prevent one death from breast cancer after approximately 14 years of observation was 1224 (CrI, 665 to 2564). Among women younger than 50 years of age, the summary relative risk associated with mammography was 0.85 (CrI, 0.73 to 0.99) and the number needed to screen to prevent one death from breast cancer after 14 years of observation was 1792 (CrI, 764 to 10 540). For clinical breast examination and breast self-examination, evidence from randomized trials is inconclusive.

Conclusions: In the randomized, controlled trials, mammography reduced breast cancer mortality rates among women 40 to 74 years of age. Greater absolute risk reduction was seen among older women. Because these results incorporate several rounds of screening, the actual number of mammograms needed to prevent one death from breast cancer is higher. In addition, each screening has associated risks and costs.

Article and Author Information

• Note: This manuscript is based on a longer systematic evidence review that was reviewed by outside experts and representatives of professional societies. A complete list of peer reviewers is available online at http://www.ahrq.gov/clinic/uspstfix.htm.

• Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

• Acknowledgments: The authors thank Stephanie Detlefsen, MD, for her contribution to this evidence review and David Atkins, MD, MPH, from the Agency for Healthcare Research and Quality and members of the U.S. Preventive Services Task Force for their comments on earlier versions of this review. They also thank Kathryn Pyle Krages, AMLS, MA, Susan Carson, MPH, Patty Davies, MS, Susan Wingenfeld, and Jim Wallace for their help with preparation of the manuscript and the full systematic evidence review.

• Grant Support: This study was conducted by the Oregon Health & Science University Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (contract no. 290-97-0018, task order no. 2), Rockville, Maryland.

• Requests for Single Reprints: Reprints are available from the Agency for Healthcare Research and Quality Web site (http://www.preventiveservices.ahrq.gov) or the Agency for Healthcare Research and Quality Publications Clearinghouse (800-358-9295).

AnnNYC

Tender, what you posted above is exactly what I described: the USPSTF commissions studies to inform their deliberations on guidelines.  The "summary of the evidence" from 2002, above, is analogous to the "summary of the evidence" published last week in Annals (by Heidi Nelson et al).