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Epi Wit & Wisdom Articles
National Cancer Institute
Ignores Advice of Consensus Panel on Mammograms
Science-Based Recommendation
“Crashes and Burns”
The Question is: Why?
In a surprising move, the
National Cancer Institute has opted to recommend routine mammograms
for all women starting at age 40. This decision reverses the NCI’s
earlier policy anchored on the opinion that the data were too
uncertain to recommend routine screening for the 40 - 49 age group.
What’s so striking about the
policy reversal is not the decision itself, but the fact that it went
contrary to the recommendations of an NIH consensus panel. This panel
was chaired by Hopkins epidemiologist Leon Gordis and it was convened
in January by NCI specifically to evaluate the data on the
effectiveness of mammograms for women 40 - 49. As covered widely in
the lay press and reported last month in the Epi Monitor, the Gordis
panel found the existing data too uncertain to recommend universal
screening for women in their 40’s. The Gordis panel said that each
woman in her 40’s should decide for herself about mammograms once
properly informed.
President’s Panel Makes
Suggestion
Rather than accepting this
advice, which supported NCI’s existing policy not to recommend
universal screening, the NCI took the advice of yet another group, the
National Cancer Advisory Board. This presidentially appointed panel,
which was constituted to review grant applications and advise the
Director, and which did not review any new data on the breast cancer
screening issue, voted 17 - 1 in February in favor of screening.
Interestingly, the lone opposing vote on that Board was that of Kay
Dickersin, a University of Maryland epidemiologist and a breast cancer
survivor. The NCI screening policy now resembles the recommendation of
the American Cancer Society for women in this age group.
The “individual choice”
screening recommendation of the Gordis panel met with strong
opposition in Congress and elsewhere among screening proponents. To
better understand why this recommendation “crashed and burned,” the
Epi Monitor spoke with some of the epidemiologists involved.
One overriding factor was the
absence of a universal health care system in the United States,
Dickersin believes, and the desire on the part of many advisors to
protect women’s rights to mammography. Without the recommendation to
screen, individual women who wanted this service might not have had it
covered under their health insurance. Also, “people are so afraid of
this disease that they want access to anything that might help,” she
said.
The Issue of Money
Another factor mentioned by
Dickersin is that many Americans hold the view that they have a right
to all medical technology and that “money is only money.” Decisions
tend not to be weighed in terms of social as well as individual good,
and “the benefit to expenditure ratio should be considered but it is
not,” she said. People who bring up money are considered crass, she
added.
A related influence on the fate
of the Gordis panel’s recommendation was that of suspected financial
interests, according to Dickersin. She noted that the interests of
HMO’s in keeping costs down were often mentioned during the debate,
but less obvious were the interests of radiologists and hospitals for
whom mammograms may be huge money makers.
Politics
Another factor is that
scientists lost control of the processes for considering the screening
question, according to CDC epidemiologist Nancy Lee. “We did it to
ourselves. In trying to have a reasoned discussion we allowed the
process to be taken over by pseudo scientists...regular scientists are
not used to people who break the rules,” she said.
The background on the screening
controversy was described in detail in a Science article on February
21, 1997 entitled “The Breast-Screening Brawl.” It stated “the
controversy over whether regular mammograms should be recommended to
women in their forties has been stoked by uncertain evidence, opposing
world views, and plenty of invective.”
Politics has been mentioned as a
big player in the NCI decision although this has been denied by the
agency. There were reports that the Director’s job was threatened by
politicians, but this has also been denied by NCI.
Senator Arlen Specter held four
congressional hearings on the subject. According to press reports, he
praised NCI’s decision to recommend routine screening, but he said he
would investigate “why it took so long to set the record straight.”
The Wrong Message
One factor which may be
surprising is the misunderstanding about mammograms themselves and
what they can accomplish. It sounds incredible, but some people
believe that mammograms actually prevent breast cancer, said Dickersin.
They confuse the difference between primary and secondary prevention
and believe that being screened once a year protects them from the
disease.
Dickersin expressed strong views
about the paternalism which she believes is also behind the decision
to give women a clear and simple statement about what to do in regards
to screening. There is a widespread belief that women “will be
confused” if there is no simple recommendation, she says. Its wrong,
she adds, because our health messages have to become more complex. She
cited the example of hormone replacement therapy as an example of a
complex message that women are dealing with. Everyone says something
is wrong if it is not simple, she said, and that itself is wrong.
Despite the route taken by their
agency, some NCI officials would welcome the more equivocal advice.
Otis W. Brawley, Director of the Office of Special Populations at NCI,
was reported in the New York Times (3/28/97, p. A15), as saying that
it would be more “honest” to give women the whole story. “I’ve always
believed in telling people what you know and then letting them decide
for themselves,” Brawley reportedly said. “To say what some people are
saying, that obviously mammography is saving lives of women in their
40s, is lying to the American people.”
Published April 1997 v
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