AAFP, Others Defend USPSTF, Breast Cancer Screening Recs in Letter to HHS

The AAFP once again has come to the defense of the U.S. Preventive Services Task Force, or USPSTF, and its recommendations for breast cancer screening.

The Academy and four of its sister organizations -- the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the North American Primary Care Research Group and the Association of Family Medicine Residency Directors -- sent a joint letter to HHS Secretary Kathleen Sebelius on May 24, voicing support for the USPSTF and the breast cancer screening recommendations the task force issued in November 2009.

The letter was in response to a May 11 letter that Sen. David Vitter, R-La., sent to Sebelius, urging HHS to require the Agency for Healthcare Research and Quality, or AHRQ, to remove the guidelines from its website. Vitter also urged Sebelius to make AHRQ and all other agencies under her authority cease promotion of the recommendations.

The guidelines were still posted on the AHRQ website as of May 26.

The family medicine organizations stressed in their letter to Sebelius that the USPSTF is "recognized as the leading independent panel of private-sector experts in prevention and primary care" and that its evidence-based recommendations are considered the "gold standard" for clinical preventive services.

"We fully support the USPSTF as an independent body to apply rigor and objectivity to the analysis of clinical preventive care -- even on issues that arouse passions," the letter said. "Our common goal is to improve the health of all Americans, and we believe the task force is the best way to ensure clinical preventive recommendations are guided by science."

It was the second time the AAFP had voiced its support for the task force and its breast cancer screening recommendations in writing. The Academy was one of 11 health care organizations that signed on to a letter to members of Congress in December after the initial recommendations caused confusion and controversy.

That confusion was due to portions of the recommendations that were poorly phrased, USPSTF Chairman and FP Ned Calonge, M.D., M.P.H., acknowledged before a House subcommittee on Dec. 2.

The USPSTF's updated guidelines recommend against routine screening mammography for women ages 40-49 who aren't at increased risk for breast cancer. That change was made as a level C recommendation, which means that although the USPSTF recommends against routinely providing the service and there is at least moderate certainty that the net benefit is small, there may be considerations that support providing it in an individual patient.

The task force said in its explanation of the recommendation change that it encourages individualized, informed decision-making about when to start mammography screening and that the decision should take into account patient context, including the patient's values regarding benefits and harms.

Possible harms that can affect all age groups include false-positive test results, overdiagnosis and unnecessary earlier treatment. However, false-positive results are more common among women ages 40-49 than those in older age groups.

The USPSTF also recommended a switch from annual to biennial screening mammography in women ages 50-74, with the intent of reducing the potential harms of screening. The task force's statement was published Nov. 17 in the Annals of Internal Medicine. The same issue includes a study that concluded that biennial screening intervals "are more efficient and provide a better balance of benefits and harms than annual intervals."

The changes caused concern among some that screenings for women younger than 50 and annual screenings would no longer be covered by insurance.

Vitter's request that the recommendations be pulled from the AHRQ website was based on an amendment he wrote to Section 2713 of the Patient Protection and Affordable Care Act. That section says that insurance plans will cover services recommended by the USPSTF, the CDC's Advisory Committee on Immunization Practices, and the Health Resources and Services Administration.

Vitter's amendment adds the stipulation that USPSTF recommendations for breast cancer screening, mammography and prevention "shall be considered the most current other than those issued in or around November 2009. Nothing in this subsection shall be construed to prohibit a plan or issuer from providing coverage for services in addition to those recommended by United States Preventive Services Task Force or to deny coverage for services that are not recommended by such Task Force."

The letter from the family medicine organizations emphasized that since 1984, the USPSTF has played a vital role in determining which clinical preventive services are effective in improving health and saving lives while avoiding the expense and harms from unproven services that can result from nonevidence-based recommendations. The organizations also advocate that the task force continue to play an important role as health care reform legislation is implemented.