Sunday, January 30, 2011

"Politics trumped science": breast cancer chemoprevention

On November 17, 2009, in the same issue of the Annals of Internal Medicine that contained the U.S. Preventive Services Task Force's controversial new recommendations on screening for breast cancer, the journal also published a report on the comparative effectiveness of medications to reduce the risk for primary breast cancer, previously known as "breast cancer chemoprevention." An earlier version of this report had been presented to the USPSTF at its March 2009 meeting, when the Task Force voted to update its 2002 recommendations on breast cancer chemoprevention. The updated statement was finalized later in the spring, and in keeping with the USPSTF's existing review process, was circulated to selected public and private medical organizations for comments. By mid-October 2009, these comments had all been received and incorporated into a final draft of the statement, which I edited as part of my role as a medical officer at the Agency for Healthcare Research and Quality.

Had the poisonous politics of mammography not intervened, it's likely that the USPSTF's new statement on breast cancer chemoprevention would have been published in Annals in early 2010. Instead, the draft was one of several statements singled out by the Obama Administration officials as being too potentially radioactive to release until after the passage of the Accountable Care Act, then after the 2010 midterm elections. In fact, it still has not been released. (As of this writing, the USPSTF has posted five other recommendations for public comment; with the exception of screening for osteoporosis, all were approved by the Task Force in March 2009 or later meetings.)

What made this delay particularly galling from a scientific perspective was that aside from containing the words "breast cancer," the new recommendation statement was unlikely to prove terribly controversial at all. The USPSTF's 2002 statement merely recommended that clinicians "discuss chemoprevention with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention," and study after study has demonstrated that very few women choose to take these drugs. It's not entirely clear why breast cancer chemoprevention (which suffers from the stigmatizing "chemo" prefix, which was deliberately removed from the USPSTF's most recent evidence report) isn't used more often: some women are concerned about the drugs' side effects, and others, unfortunately, probably believe that routine mammograms make them invulnerable. (In fact, mammography reduces the risk of death from breast cancer by about 25%, at best, in women age 50 to 74 years.)

I was not present at the high-level meeting in which the Administration determined that the political risk of releasing even a draft recommendation statement about breast cancer chemoprevention outweighed the merits of allowing clinicians and patients to make medical decisions informed by the latest evidence. But I wouldn't be surprised if some staffer with little or no medical background, taking a look at the long backlog of USPSTF statements, zoomed in on the words "breast cancer" and made a spur-of-the-moment decision that may have lasting negative implications for women's health.

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