This past week, the US Preventive Services Task Force (USPSTF) issued its revised recommendations for breast cancer screening and mammography and set off a firestorm of criticism. Among the controversial items was changing initial mammography screening from 40 to 50 years of age, recommending mammography every two years instead of one, and urging an end to the teaching of breast self-examination.
There is a valuable lesson for FDA in how the announcement and aftermath unfolded.
FDA Matters is amazed at how unprepared the Task Force seemed to be for criticisms from individual patients, health professional groups and Members of Congress. It is as if they were unaware of how much comment, confusion, and dissent their views were going to generate. The Agency for Heathcare Research and Quality (AHRQ), which provides support for the Task Force, seemed no better prepared.
There may be a number of reasons why the Task Force didn’t see the need to prepare better or didn’t care about the responses they would receive. One possibility is that the USPSTF is made up of primary care doctors and statisticians and doesn’t reflect the broader perspective of medical specialists, who provide much of the nation’s care.
There is also a deep schism between those relying on statistical modeling (such as the Task Force) and those believing that common sense, patient need and clinical experience should be weighed before decisions are made. Ultimately, the Task Force conducted its business in a bubble, isolated from public discourse and perceptions and with no accountability to the women whose lives will be impacted.
In contrast, the American College of Obstetrics and Gynecology (ACOG) released its recommendations later in the week, calling for less frequent screening for cervical cancer and for screening to be initiated at a later age. Their views received appropriate attention, but generated very little controversy.
ACOG supported their position with analyses that pointed to when and how cases are identified in this slower growing cancer. They documented clinical consequences (not just cost impacts) of additional unneeded diagnostic and treatment activities. Clearly, they had engaged practitioners and other organizations in their process…and had taken their input seriously.
There is a constant tension between high-minded decisions and the realities of clinical diagnosis and care. FDA must balance these every day. Some days they do better than others.
Risk Evaluation and Mitigation Strategies (REMS), a relatively new FDA patient safety and communications initiative, represents an area that will constantly challenge the agency’s ability to balance stringent purity with “real world” practicality. Under a REMS agreement with a biopharmaceutical company, FDA tries to assure that the risks of approved products are properly communicated to healthcare professionals and patients and that systems have been put into place to reduce potential adverse events and treatment failures.
To date, most REMS programs appear to reflect the complexity of drug information and distribution. Greater challenges lay ahead….and FDA may struggle to communicate its decisions and rationale well.
If FDA lives in a bubble, unprepared for people’s perceptions and needs, then REMS will become a major area of controversy. As ACOG demonstrated this week, it is possible to communicate the value of new approaches to good medicine, without losing sight of what is understandable and useful for patients.
I think that Drs. Hamburg and Sharfstein have made a good start at opening up FDA’s insular world. Their experiences in running big-city health departments have taught them to value real-world solutions, geared to the majority of Americans who live outside the bubble and want to understand decisions that affect them.
Steven
Ultimately, what disappoints me is the Task Force’s (and AHRQ’s) lack of interest in being understood. The firestorm was very predictable…but they don’t appear to have done anything to anticipate it and show why their logic and facts are meaningful to women who fear breast cancer (which is, I believe, all women). Announcing such recommendations in an academic journal and through a white paper that requires a google search to find…doesn’t cut it.
In defending the substance of the TF’s recommendations, friend and felllow blogger, Merrill Goozner’s highlights what should have been the key point: if we spend $2.2 billion each year on mammography that is not cost-effective….how could we better spend those dollars to prevent and detect breast cancer? http://www.gooznews.com/node/3174.
Steven