Today’s Managing Health Care Costs Number is 813
Cover your ears!
Today’s Annals of Internal Medicine has the most recent US Preventive Services Task Force evidence-based recommendation on mammographic screening for women. The recommendation is unchanged from 2009, when it caused a firestorm:
A “B” finding is a recommendation – in this case with high certainty of moderate benefit. Under the Affordable Care Act rules, health plans must provide first dollar (no deductible, no out of pocket cost) coverage for services with a “B” recommendation. Note that this is a recommendation for screening every two years, not every year. It is also relevant to women of average risk. Women at higher risk should continue to be screened more frequently.
A “C” finding is that there is moderate certainty that the benefit is small, and clinicians should use their own professional judgment about whether or not to recommend the service.
An “I” finding is that there is not enough evidence to distinguish whether the service is beneficial or harmful.
There was a minor uproar when the draft of these came out last Spring - so perhaps there will be no furor. Congress already extended the requirement that health plans provide coverage for screening mammography for women under 50, so there is no coverage implication. The academicians who make the USPSTF are adamant that their deliberations are to inform clinical decisions, and are not at all happy that the ACA has politicized the recommendations by making them determinants of coverage.
This issue of Annals has an article that models the likely excess deaths from breast cancer from annual (vs. biennial) mammography.
Annual screening of 100 000 women aged 40 to 74 years was projected to induce 125 breast cancer cases (95% CI, 88 to 178) leading to 16 deaths (CI, 11 to 23), relative to 968 breast cancer deaths averted by early detection from screening. Women exposed at the 95th percentile were projected to develop 246 cases of radiation-induced breast cancer leading to 32 deaths per 100 000 women. Women with large breasts requiring extra views for complete examination (8% of population) were projected to have greater radiation-induced breast cancer risk (266 cancer cases and 35 deaths per 100 000 women) than other women (113 cancer cases and 15 deaths per 100 000 women). Biennial screening starting at age 50 years reduced risk for radiation-induced cancer 5-fold.
Last Spring, advocacy groups took out large, expensive ads decrying the USPSTF guidelines. One ad asked “Which of our mothers, wives, daughters, and sisters would it be OK to lose?” The data on real harms of screening, including overdiagnosisand excess breast cancers due to mammography, are a good reason not to do more mammography on average risk women than the USPSTF recommends.
Note - I multiplied cases and deaths per 100,000 by 2010 census figures to obtain the graphic above This shows 813 incremental deaths from breast cancer from doing mammography annually from age 40 rather than biennially from age 50.
