Back to Making Sense of the Task Force Recommendations on Mammography
Frequently Asked Questions About Task Force Recommendations
- Are the U.S. Preventive Services Task Force recommendations in effect right now?
- Will insurance companies change their coverage? What determines whether insurance companies will change their coverage?
- What is the actual radiation risk of mammograms?
- Who appoints task force members and what weight does their opinion carry?
- What makes someone at high risk for breast cancer?
- Should I stop doing breast self-exam?
- What is the government saying about these recommendations?
Are the U.S. Preventive Services Task Force recommendations in effect right now?
The task force recommendations are not in effect now. Currently, women can continue to receive their annual routine screening mammograms if they are age 40 and older.
Will insurance companies change their coverage? What determines whether insurance companies will change their coverage?
Irene Card, president of Medical Insurance Claims, Inc., says, "It is not likely that insurance carriers will change coverage. Usually the Department of Insurance in a particular state has to approve any changes insurance carriers make." Ms. Card is the former insurance advisor to the National Coalition for Cancer Survivorship and Memorial Sloan-Kettering Post Treatment Resource Program.
More specific information was reported in the November 19, 2009 edition of USA TODAY:
"Some of the companies that told USA TODAY that they will continue paying for mammograms for women in their 40s include Kaiser Permanente, Aetna, Cigna, Geisinger Health Plan, Group Health Cooperative and WellPoint, which operates Blue Cross/Blue Shield plans in 14 states. Together, these plans cover more than 73 million people."
This doesn't necessarily mean that insurance companies won't consider making changes in the future. A November 18, 2009 statement on Kaiser Permanente's News Center web site says, "We do not currently plan on making any changes to our coverage or treatment practices, based on the U.S. Preventive Services Task Force's recent announcement on breast cancer screening. … We look forward to taking part in additional, informed discussions about the USPSTF recommendations with the National Committee for Quality Assurance and other organizations in the months to come."
As for Medicare coverage, Dan Pfeiffer, President Obama's deputy communications director, reported on his November 17, 2009 White House Blog, "Women who are currently getting mammograms under Medicare will continue to be able to get them. There are no plans to change that. The law states that in order to change Medicare coverage of mammograms a formal rule making process must be undertaken and that is not happening."
What is the actual radiation risk of mammograms?
Key things to know about radiation exposure and mammograms:
- Exposure to LARGE amounts of radiation can cause cancer.
- The amount of radiation exposure from screening mammograms is VERY SMALL. The U.S. Preventive Services Task Force, which recommended a dramatic change in mammogram screening policy, acknowledged that radiation exposure from screening mammograms is small.
- The link between breast and other cancers and exposure to radiation from screening mammograms has been investigated in a number of studies. There is no consistent evidence that cancer is caused by screening mammograms.
Who appoints task force members and what weight does their opinion carry?
The U.S. Preventive Services Task Force was first convened by the U.S. Public Health Service in 1984. Since 1998 it's been sponsored by the Agency for Healthcare Research and Quality, which is part of the U.S. Department of Health and Human Services. The task force is an independent panel of private-sector experts in prevention and primary care.
For each preventive/screening service, the task force reviews evidence, estimates risks and benefits, decides the overall benefit, and issues a recommendation.
The task force is made up of primary care givers -- internists, pediatricians, family physicians, gynecologists/obstetricians, and nurses.
The Agency for Healthcare Research and Quality asks for nominations for task force members through an open process announced in the Federal Register, an official publication for notices from federal agencies and organizations. Anyone can nominate a candidate for the task force and people can nominate themselves to be members. Members are selected based on expertise in prevention, evidence-based medicine, and primary care.
This appears to be why there are no cancer doctors on the task force -- membership is limited to primary care givers. Whether this will change in light of the recent mammogram controversy is unclear.
In an interview with Katie Couric on CBS Evening News on November 18, 2009, Department of Health and Human Services Secretary Kathleen Sebelius said that task force members were "appointed by President George Bush" and had "been on the panel a long time." But it's not clear if task force members serve for a specific period of time or are members for as long as they choose to be.
The main audience for task force recommendations is primary care doctors. But according to the task force's web site, task force recommendations also have been used by medical associations to develop their recommendations and by many health plans and insurers to determine coverage.
So while some task force members have been saying in the media that they don't influence insurance coverage, the group's own web site says it does.
What makes someone at high risk for breast cancer?
High risk factors for breast cancer are:
- Family history of breast cancer. Breast cancer risk is higher among women with close blood relatives that have been diagnosed. Having a first-degree relative (mother, sister, or daughter) diagnosed with breast cancer nearly doubles a woman's risk. Having two first-degree relatives diagnosed makes a woman's risk about 5 times higher.
- Abnormal BRCA1 or BRCA2 genes. Most inherited cases of breast cancer have been associated with two genes: BRCA1, which stands for BReast CAncer gene one, and BRCA2, or BReast CAncer gene two. Abnormal BRCA1 and BRCA2 genes may account for up to 10% of all breast cancers. Women diagnosed with breast cancer who have an abnormal BRCA1 or BRCA2 gene often have a family history of breast cancer, ovarian cancer, or both. Read more about Genetics and Breast Cancer Risk.
- Personal history of breast cancer. A woman diagnosed with cancer in one breast is 3 to 4 times more likely than average to develop a new cancer in the other breast or in another part of the same breast. This risk of a new cancer is different from the risk of the first cancer coming back (recurrence).
- LCIS. Women diagnosed with LCIS (lobular carcinoma in situ) are 7 to 11 times more likely than the average women to develop cancer in either breast.
- Atypical hyperplasia. Women diagnosed with atypical hyperplasia (excessive growth of cells that don't seem to be normal in the breast tissue) are 4 to 5 times more likely to develop breast cancer.
- Previous chest radiation. Anyone who had chest radiation therapy to treat another type of cancer (Hodgkin's lymphoma or non-Hodgkin's lymphoma) as a child or teen has a higher-than-average risk of breast cancer. The amount of increase in risk depends on the age when radiation was given.
- DES (diethylstilbestrol) exposure. DES is an estrogen-like hormone used in the past to help women prevent miscarriage. Daughters of women who used DES have an increased risk of cancer of the vagina. This drug also may increase the risk of breast cancer in women who used it and in their daughters who were also exposed to it.
For more information on risk factors, please see the Breastcancer.org section on Risk Factors You Can't Control.
Should I stop doing breast self-exam?
No. Twenty percent of women’s breast cancers are found only by physical exam -- a visible or palpable abnormality that you or your doctor is able to see or feel on examination -- not mammography. In women under age 50, an even greater proportion of breast cancers are found by breast self-exam. An individual woman's self-examination may be her main opportunity for early detection with a potential survival benefit. While she acknowledges that there are clear limitations to what breast self-exams can detect and at what stage, Dr. Marisa Weiss says, "What's important is that women are encouraged to use all three tools -- breast self-exam, clinical breast exam by a healthcare practitioner, and mammography -- to maximize the chance of early detection." Learn how to do a breast self-exam.
What is the government saying about these recommendations?
Because many women, cancer doctors, and medical organizations have expressed strong views against the U.S. Preventive Services Task Force recommendations, Department of Health and Human Services Secretary Kathleen Sebelius issued a written statement on November 18, 2009 to address the confusion, saying that the recommendations will not affect government policy and should not impact private insurers' policies:
"There is no question that the U.S. Preventive Services Task Force Recommendations have caused a great deal of confusion and worry among women and their families across this country. I want to address that confusion head on. The U.S. Preventive Task Force is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy and they don’t determine what services are covered by the federal government.
"There has been debate in this country for years about the age at which routine screening mammograms should begin and how often they should be given. The task force has presented some new evidence for consideration but our policies remain unchanged. Indeed, I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action.
"What is clear is that there is a great need for more evidence, more research, and more scientific innovation to help women prevent, detect, and fight breast cancer, the second leading cause of cancer deaths among women.
"My message to women is simple. Mammograms have always been an important life-saving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years -- talk to your doctor about your individual history, ask questions, and make the decision that is right for you."
On his November 17, 2009 White House Blog, Dan Pfeiffer, President Obama's deputy communications director, wrote that the Task Force has no power to deny insurance coverage in any way. He also says:
- "Women who are currently getting mammograms under Medicare will continue to be able to get them. There are no plans to change that."
- "The Task Force does not address insurance coverage and payment issues; it focuses on the science of the clinical services it evaluates. Each insurance company is different and makes its own coverage decisions. The Task Force recognizes that clinical and policy decisions involve more consideration that this body of evidence alone. Clinicians and policymakers should understand the evidence but individualize decision making to the specific patient or situation."
- "We have tremendous respect for the Task Force and the work they have done. They are an independent scientific body that makes recommendations based on scientific evidence; however they do not set official policy for the federal government. Under health reform, their recommendations would be used to identify preventive services that must be provided for little or no cost."