If the "third rail" of the U.S. health care system is Medicare, the third rail of preventive medicine is screening mammography. History has shown that North American evidence-based medicine panels are imperiled when they suggest that breast cancer screening can be optional for women younger than 50, even if that happens to be the norm for the rest of the world.
In November 2009, advocacy groups came close to fatally wounding the U.S. Preventive Services Task Force (USPSTF) after it downgraded screening mammography in average-risk women aged 40 to 49 from a "B" (do routinely) to a "C" (do selectively with shared decision-making) grade. Armed with advocacy talking points, politicians from both parties subjected the USPSTF to withering attacks, and Republicans darkly predicted that the health reform legislation then under consideration in Congress (which eventually became the Affordable Care Act of 2010) would lead to widespread rationing of all kinds of health care. Then-Secretary of Health and Human Services Kathleen Sebelius publicly disavowed the recommendations and tried to blame the previous administration for having appointed the members who voted for the changes. Public affairs personnel at the Agency for Healthcare Research and Quality (AHRQ), where I worked, were prevented from assisting USPSTF members with media appearances explaining the recommendations.
The USPSTF eventually recovered and even thrived from 2010 to 2025, becoming more influential and for the most part, managing to keep politics at bay. However, it is facing a different sort of existential crisis under the second Trump administration, not being allowed to meet for the past 16 months and having its support team at AHRQ eviscerated to the point where it's not clear how the panel would function even if HHS Secretary RFK Jr. eventually appoints new members to replace the ones he fired.
Meanwhile, the Canadian Task Force on Preventive Health Care, the original model for the USPSTF, was disbanded earlier this year, a victim of a similar breast cancer screening recommendation that the federal health minister never allowed to be finalized. As Dr. Guylene Theriault, the former chair of the Canadian Task Force, recently wrote in BMJ Evidence-Based Medicine:
The evidence-based guidance conflicted with certain lobbyists' arguments and elected officials' beliefs in the unambiguous positive outcomes of screening. Ultimately, these arguments and perceptions prevailed over rigorous scientific evidence, making it more difficult for a woman to access clear, unbiased information on which to base her decisions. Perhaps naively, the Task Force members and I thought that placing the patient at the center of the decision-making process would be something everyone could agree on. We were wrong.
A recent study in the American Journal of Preventive Medicine documented worrisome trends in primary care associated with the sidelining of the USPSTF and the remaking of the Advisory Committee on Immunization Practices:
Clinicians report that patients are increasingly hesitant about vaccines and preventive services. For example: 64% report patients are confused as to what vaccination guidelines they should follow; 46% report parents are expressing new hesitancy about childhood vaccinations; 36% report patients are declining preventive services they previously accepted. Most responding clinicians (58%) report spending more visit time explaining the evidence behind clinical recommendations, and 61% report patients more frequently are seeking information from non-medical sources.
