AMA Delegates Call for Adding 'Physicians With Expertise' to Government Guideline Panels

USPSTF Breast Cancer Screening Recommendations Generate Lengthy Debate

June 18, 2010 04:55 pm David Mitchell

Delegates to the 2010 annual meeting of the AMA House of Delegates in Chicago adopted a measure on June 15 that directs the AMA to "encourage government panels and task forces dealing with specific disease entities to have representation by physicians with expertise in those diseases."

A second part of the same resolution, calling specifically for physicians to follow the American Cancer Society's guidelines( for breast cancer screening, was referred to the AMA Board of Trustees.

The resolution was introduced by the Illinois delegation to the AMA in response to controversial screening guidelines released by the U.S. Preventive Services Task Force, or USPSTF, in November 2009.

USPSTF Guidance Proves Controversial

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 task force 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 revised recommendations 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.

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.

Critics have blasted the task force's recommendations, however, with some fearing the changes might prompt payers to reject coverage for annual screening or for screening women younger than 50. Others have pointed out that the USPSTF( comprises primary care physicians, epidemiologists and public health experts, but does not include subspecialist physicians.

The Illinois resolution, in fact, referred to the task force as being made up of "public health academics and medical statisticians, with no representation by physicians involved in the diagnosis or treatment of breast cancer."

AAFP Leaders Support Primary Care Experts

AAFP president-elect Roland Goertz, M.D., M.B.A., of Waco, Texas, and AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho, both testified in opposition to the resolution during a June 13 hearing of the AMA's science and technology reference committee.

Goertz subsequently told AAFP News Now that primary care physicians are well suited for such independent expert panels because they don't have the biases or special interests of a surgeon or radiologist. He said it was unfortunate that both resolves were not referred for additional study.

"There was a tremendous amount of debate about whether the AMA should be involved in trying to resolve conflicting recommendations," said Goertz.

In its report, the science and technology reference committee rejected the Illinois delegation's resolve that encouraged adherence to the American Cancer Society's recommendations and instead recommended amending existing AMA policy to support evidence-based guidelines and oppose the use of guidelines by the federal government or payers to restrict access to screening.

That amendment, however, was voted down by the AMA house, and the measure was referred to the board.

The AAFP's breast cancer screening recommendations are based on the updated USPSTF guidelines, and the Academy has defended the task force in letters to Congress and HHS.

Smoking and Nutrition Measures Adopted

Delegates at the meeting also adopted a number of measures related to smoking. Recommendations in a report developed by the AMA Council on Science and Public Health direct the AMA to urge that

  • electronic cigarettes, or e-cigarettes, be classified as drug delivery devices, making them subject to FDA regulation;
  • state legislatures prohibit the sale of e-cigarettes that are not FDA-approved; and
  • e-cigarettes be subject to smoke-free laws just as traditional cigarettes are.

A separate measure that delegates adopted calls for the AMA to encourage

  • federal, state and local housing authorities and governments to prohibit smoking in multiunit housing to protect children and adult nonsmokers; and
  • state and local medical societies, chapters and other health organizations to support and advocate changes in existing state and local laws and policies to achieve such prohibitions.

In addition, delegates called on the AMA to urge the FDA to use more precise processes to measure the fat content in foods, particularly transfats and saturated fats. Current FDA labeling requirements allow foods designated as containing zero transfats to actually provide a significant amount of a person's recommended daily allowance of fat. The measure urges the FDA to require that the most accurate fat content information be included on food labels.

Delegates also directed the AMA to support efforts to decrease the price gap between inexpensive calorie-dense, nutrition-poor foods and more costly naturally nutrition-dense foods to improve health in economically disadvantaged populations. This, they said, should be done as part of the Women, Infants and Children program by encouraging expanded funding for and enrollment in existing programs that seek to improve nutrition and reduce obesity. The delegates also called on the AMA to support the application of program models that provide incentives for the consumption of such naturally calorie-dense foods.