Protecting Women’s Access to Screening Mammography
These members of Congress got it right.
In August, Senators Keely Ayotte (R-NH) and Barbara Mikulski (D-MD) introduced the Protect Access to Lifesaving Screenings (PALS) Act (S. 1926) in the U.S. Senate.
As its name says, this legislation aims to protect access to annual screening mammography for women ages 40 to 74.
Congresswomen Renee Ellmers (R-NC) and Debbie Wasserman Schultz (D-FL) introduced similar legislation in the House of Representatives.
The legislation places a two-year moratorium on payers using the United States Preventive Services Task Force (USPSTF) draft breast cancer screening recommendations to deny coverage or require co-pays from patients undergoing mammographic screening.
If passed, it will allow time for Congress and others to review the impact USPSTF recommendations will have on women seeking screening for breast cancer. For similar reasons, the Doctors Caucus (made up of physician members of Congress) in the House of Representatives sent a letter to Health and Human Services Secretary Sylvia M. Burwell asking that the USPSTF recommendations not be used to change women’s access to breast cancer screening.
I believe these actions are the right thing for the Congress to do to promote informed decision-making about when to begin breast cancer screening.
The draft recommendations of the United States USPSTF released for public comment in April 2015 remain at odds with those of the ACR and many other specialty societies whose members have expertise in breast cancer care.
The USPSTF maintains its previous “C” recommendation that, for women at average risk for breast cancer, the decision when to start screening mammography is an individual one. The USPSTF “C” recommendations are defined as follows: “the USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences.”1 For screening mammography, the task force states that while beginning screening at age 40 reduces a woman’s risk of dying from breast cancer, the number of lives saved is much smaller in this age group than in older women.
The task force described its decision as follows:
USPSTF concluded that the benefit of screening mammography outweighs the harms in this age range, but only by a small amount. It [the “C” recommendation] is an acknowledgement that the balance of benefits and harms for any individual woman in this age group is a delicate one. Women ages 40 to 49 years must weigh a very important but infrequent benefit (small reduction in breast cancer deaths) against a group of meaningful and much more common harms (overdiagnosis and overtreatment; unnecessary and sometimes invasive followup testing and psychological harms associated with false-positive tests; and false reassurance from false-negative tests). Women who value the possible benefit of screening mammography more than they value avoiding its harms can make an informed decision to begin screening.
The lack of consensus on the number of lives saved by early diagnosis and the ambiguity around the true harms from breast cancer screening mean the USPSTF recommendations will continue to be controversial. As a radiologist, I am aware of the evidence that continues to demonstrate annual screening mammograms reduce breast cancer mortality, which in my opinion, outweighs the harms of a false-positive diagnosis.
But I also recognize that others have differing opinions, and perhaps we have more work to do to understand the risks of DCIS and minimally invasive carcinoma in order to develop more appropriate treatment options. Despite the focus on the potential harms of screening for breast cancer, the task force acknowledged that more lives will be saved when screening begins at age 40. For this reason, I expect that many if not most women will continue to elect to begin screening at age 40.
However, this good-faith effort to place decision-making in the hands of patients is threatened by the task force’s “C” recommendation. It creates aignificant dilemma and perhaps an unintended consequence for payers, patients, and physicians.
The Affordable Care Act has a provision that requires third-party payers to cover preventive services that receive USPSTF “A” or “B” recommendations without any co-pay. If insurers follow the provisions of the ACA, they may require a co-pay for screening mammography for patients in their 40s or, worse, may not provide coverage at all. In that case, patients may be making their decision on when to begin screening based on financial considerations rather than by weighing the benefits versus the harms the USPSTF suggests.
A woman’s decision on when to begin screening can be truly informed by a shared decision-making process with her doctor only if out-of-pocket costs for mammography are not a consideration. Senators Ayotte and Mikulski and Congresswomen Ellmers and Wasserman Schultz recognized the impact of the ACA on the USPSTF recommendation to place more decision-making power in the hands of women and their physicians. These members of Congress are taking measures to ensure access to mammography for women in their 40s. I applaud them for their effort to make sure that a woman’s decision on when to begin screening is informed by the data and not by the costs.
By Bibb Allen Jr., MD, FACR, Chair