Sunday, November 22, 2009

Mammograms and USPSTF

Recently, the U.S. Preventive Services Task Force (USPSTF) announced that mammograms should start at age 50 and be every 2 years after that. The American College of Obstetricians and Gynecologists (ACOG) had recommendations for yearly mammograms starting at age 40. ACOG posted their response to the USPSTF recommendations. Some people have talked about the USPSTF being the death panel. I disagree.

USPSTF is a government organization that has been around since 1984. In the past 25 years, they've only issued 126 recommendations. They are extremely conservative in that only strongly proven prevention services would be recommended. They have always been that way. Doctors understand that they must do what the USPSTF recommends AND MORE! The guidelines from USPSTF are just the minimum prevention services a doctor should provide. Most doctors provide much more than what they recommend.

Most professional doctor organizations have their own set of recommendations irrespective of the USPSTF. Most doctors follow their professional organization's recommendations, because that is considered the "standard of care." The "standard of care" is what a doctor faces in court, if there is ever a lawsuit. If every doctor in your county checks the PSA (prostate specific antigen - a prostate cancer test) at age 50, then that is considered the standard of care. However, the USPSTF has always recommended against checking the PSA because it has never been shown to improve lifespan. Doctors do not always follow the USPSTF guidelines.

Another example is the Pap smear. The USPSTF says that Pap smear should start at age 21 and be done every three years. The common practice for many physicians is to start Pap smears when sexual activity starts and continue yearly. I have even heard of one physician that insists on checking every six months. I do not think that physician is practicing the standard of care. Similarly, a physician who checks only every three years for a woman in her 20's is not practicing the standard of care. ACOG recently (this month) issued a recommendation similar to the USPSTF. We'll see how quickly these new guidelines are adopted by the general medical community. I wouldn't be surprised if my gynecologist insists seeing me again this year even though everything was normal last year.

The thing is, doing too many Pap smears and PSA tests result in too many follow up procedures and too many worried patients for no good reason. Most abnormal pap smears will go away within a year. The HPV infection that caused the abnormal pap is usually killed off by the body's own immune system. It is extremely rare that a temporarily abnormal pap smear will eventually result in cervical cancer. Yet, if there are certain changes found on a Pap, we would do a colposcopy, which is a biopsy. And if the biopsy shows more HPV infection and cell changes, then we'll cut off part of the cervix or freeze it off. That can result in scarring that causes a cervix unable to hold in a baby (so it has to be sewn together during pregnancy and mother placed on extended bedrest) or a cervix that cannot deliver a baby (requiring a C-section). We are likely causing more treatments and complications than necessary currently.

As for PSA testing, I generally recommend against it unless the patient insists or believes that it is the right thing to do. If it's positive, then a biopsy may be necessary. Approximately 70% of 70 year old men have prostate cancer cells somewhere in their prostate. So they come back with a diagnosis of prostate cancer and then require surgery, radioactive beads, or some other treatment. The complications from the prostate cancer treatments are extremely unpleasant. Because of the location, some will end up with urinary incontinence. And some men end up having to learn self-catheterization, where they stick in the tube a few times a day to empty their bladder. Some will have rectal problems. Most 70 year old men die of heart disease, stroke, or some other cancer, not prostate cancer. Most prostate cancers are extremely slow growing and do not cause any problems. They do not need always require treatment.

Some of the commonly accepted preventive services look for problems too early. That results in worse health care because we end up doing too many further tests, interventions, and procedures that cause complications. So yes, some preventive services cause more problems than they prevent.

Looking at countries that have better healthcare outcomes than ours, one will see that their standard of care is more similar to the USPSTF than the professional doctor's associations. USPSTF looks at cost benefit ratios and overall outcomes of doing screening tests. The professional doctor's associations may care a bit more about making their doctors more money.

Go back to the mammogram recommendation. Canada and the UK start pap smears and mammograms later and more infrequently. They have better overall outcomes than us. If we change our practices with mammograms and pap smears, we may achieve better outcomes. There is nothing "death panel" about worrying less and having better overall outcomes.

No comments:

Post a Comment