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Mammogram proposal threatens to reignite screening battle

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(Bloomberg) — A decision from a panel of U.S. doctors and health experts threatens to reignite the debate over how much breast cancer screening is appropriate, potentially opening the door for insurers to stop covering some mammograms.

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In a draft proposal, the U.S. Preventive Services Task Force (USPSTF) said Monday that most women under 50 may not need regular mammograms to look for breast cancer. The Patient Protection and Affordable Care Act (PPACA) generally lets insurers limit coverage for screenings that the panel doesn’t back. The law currently requires them to adhere to guidelines calling for women ages 40 and older to have mammograms every one to two years.

The panel is attempting to weigh the benefits and harms of screening for breast cancer. Because the disease becomes more common as women get older, the screening is most helpful for those over 50, the panel said.

Younger women are significantly more likely to experience a false positive result and undergo additional procedures including biopsies to rule out a cancer that isn’t present, said Michael LeFevre, the task force’s past chairman. Others get treatment for conditions that would never harm them. The data show that mammograms would prevent 4 deaths for every 10,000 women ages 40 to 49 who undergo screening for a decade.

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“This is the best balance of benefits and harms,” said LeFevre, a professor at the University of Missouri School of Medicine. “Breast cancer is an uncommon disease for women in their 40s.” The independent panel weighs medical evidence only, not costs.

Unnecessary treatment

False positives, where women undergo additional procedures to rule out a suspicious finding on mammography, occur in 1,212 of every 10,000 women age 40 to 49, according to a report by the panel. About one in five women diagnosed based on mammography get treatment for a cancer that otherwise would have gone undetected or never caused health problems, according to the report.

The proposal is open for public comment through May 18, after which the task force will make a final recommendation.

“Because USPSTF recommendations are often used by insurance companies and government programs to determine coverage, we are concerned that women and their health care providers will be deterred from screening that might be appropriate,” said Judith Salerno, president of the Susan G. Komen breast cancer foundation. “Worse yet, the recommendations may cause women under 50 to delay paying attention to their breast health and breast cancer risk.”

Benefits and Risks

The new guidelines overstate the harms of screening and understate the benefits, said Barbara Monsees, chairwoman of the American College of Radiology’s Breast Imaging Commission. She said the guidelines could reduce coverage for the screening and discourage doctors from recommending mammograms.

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Because the guidelines could affect insurance coverage, women who don’t have the means to afford mammograms will be particularly affected, Monsees said.

“It’s going to unduly affect women who don’t have the same sort of income and that’s a very unfortunate consequence,” she said. “It’s going to discourage screening.”

The panel’s proposal is the same as the recommendation it made in 2009, when the Affordable Care Act was working its way through Congress. That recommendation proved so controversial that a provision of the Affordable Care Act effectively told insurers to ignore it. That provision doesn’t apply to subsequent recommendations from the task force, which means insurers won’t have to ignore the new proposal if it becomes final.

Congress reacts

The proposal drew immediate criticism on Monday from two senior Democrats in the House of Representatives.

Representative Debbie Wasserman Schultz, of Florida, said the recommendations would be “a significant step in the wrong direction.” “As a young breast cancer survivor, I strongly believe we need more, not less, preventive services,” Wasserman Schultz said in an e-mailed statement.

“The real issue is that far too few women receive mammograms at all,” said Representative Rosa DeLauro of Connecticut, the top Democrat on the House Appropriations subcommittee on Labor, Health and Human Services, Education and Related Agencies. “Mammography is not perfect, but right now it is the best method we have to detect and treat breast cancer,” said DeLauro, in an emailed statement.

The findings conflict with a recommendation from the American Cancer Society for annual mammograms starting at age 40, though the group is reviewing its recommendations, said Richard Wender, the group’s chief cancer control officer.

Outweighing harms

The American Cancer Society thinks that the benefits of screening outweigh the harms at 40, and that women should discuss with doctors whether to undergo mammograms, he said. Most commercial insurers currently pay for annual mammograms, and the cancer group thinks that coverage should continue, he said.

“The likelihood that commercial payers in any substantial number would withdraw funding is slight,” he said. “I think they’d have a real backlash from their insured constituents.”

UnitedHealth Group Inc. (NYSE:UNH), Anthem Inc. (NYSE:ANTM) and Aetna Inc. (NYSE:AET), the nation’s biggest insurers, currently cover mammograms for women 40 and up. Spokeswomen for Anthem and Aetna said the companies would review the task force’s guidelines and decide whether to make any changes.

“Because the recommendations are draft, nothing has changed as far as access to mammograms or other preventive services that insurers are required to cover with no cost sharing,” the U.S. Department of Health and Human Services (HHS) said in a statement.

The panel said that women ages 40 to 49 should discuss with their doctors whether to get the screening, and gave the test a grade of C, meaning doctors should provide the service for selected patients based on individual circumstances. Women from 50 to 74 should get a mammogram every other year, according to the doctor panel, which gave that guideline a B rating. Insurers are required to cover screenings that have an A or B rating from the task force.

“We are helping fewer women, and we are harming more, but the benefits still outweigh the risks by a small amount,” said LeFevre, the past chairman of the task force. That’s why the group recommended that women in their 40s make a decision about screening independently with their doctors. “We want women to have this knowledge.”

—With assistance from Billy House in Washington.

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