In November 2009, I was a medical officer with the U.S. Preventive Services Task Force (USPSTF) at the Agency for Healthcare Research and Quality. The health reform legislation that would eventually become law as the Affordable Care Act (or "Obamacare" after then-president Obama) was being fiercely debated in Congress. Politicians who opposed expanding health insurance to the poor, self-employed, and employees of small businesses launched all sorts of spurious charges, the worst being that the law would establish "death panels" that would determine whether elderly patients with chronic medical conditions would be allowed to live or die. Into this political maelstrom stepped the USPSTF, releasing an ill-timed update that recommended against routinely screening women aged 40-49 for breast cancer. Contrary to popular belief, this language didn't mean they were advising all women in this age group NOT to be screened; instead, they were empowering patients to make this decision individually in consultation with their physicians, based on their preferences and values.
The current Task Force looked at essentially the same evidence and come to a different conclusion: start screening everybody at age 40, never mind the potential harms. In a Medscape commentary, I explained why I don't believe this change is justified. However, it put a great deal of pressure on our neighbors to the north and the Canadian Task Force on Preventive Health Care to reassess its recommendations and come to a similar conclusion. If Americans are getting screened for breast cancer in their 40s, why shouldn't Canadians too?
The Canadian Task Force released its draft recommendations two weeks ago. In short, they echo the USPSTF's recommendations in 2009 and 2016 and maintain that breast cancer screening should be a "personal choice," particularly for females younger than age 50. "For women aged 40 to 49, based on the current evidence (trials, observational studies, modelling and a review on values and preferences), we suggest not to systematically screen with mammography [emphasis mine]. Because individual values and preferences may differ, those who want to be screened after being informed of the benefits and harms should be offered screening every 2 to 3 years." The supporting data, much of it derived from systematic reviews, is extensive and compelling, including discussion tools for women in various age groups.
Unlike the U.S. 15 years ago, Canada isn't in the midst of a major health reform debate - they've already had an equitable universal health care system for decades, thank you very much. But that hasn't stopped one health official from trying to score cheap political points. The Canadian Minister of Health, Mark Holland, a lifelong politician without any health professions training, has forcefully objected to the CTFPHC's draft recommendations and ordered an unprecedented "external review" that will, no doubt, include conflicted experts such as radiologists who have obvious financial incentives to perform as many mammograms on asymptomatic women as possible.
Here is Holland being interviewed on an Ottawa news channel. When the anchor asks him what he would do if the external review confirms the Task Force's recommendations, he dodges and weaves and avoids answering.
As a former USPSTF member once said, "we can follow the evidence wherever it leads," or we can start with a preordained conclusion and cherry-pick data that supports what we already know to be true. Canada, Mark Holland, and the CTFPHC would do well not to mimic the most expensive, inequitable health care system in the world and associate higher percentages of women receiving mammography in their 40s with better preventive care "quality."
