Bloomberg recently reported a story that highlighted the recommendations of the U.S. Preventive Service Task Force on yearly mammograms for women aged 40 and above. According to the story, the guidelines released by the task force suggested that annual mammograms for most women in their 40s have more drawbacks than benefits and therefore, women should wait until age 50 to start getting breast cancer screening tests every two years.

Here is the story:

November 17, 2009

Annual mammograms for most women in their 40s have more drawbacks than benefits, said a panel of U.S. doctors that recommended women wait until age 50 to start getting breast cancer screening tests every two years.

The change in guidelines released by the U.S. Preventive Service Task Force, a government-backed physician group, said women in their 40s are more likely to get false-positive tests that can lead to unnecessary biopsies and anxiety. The recommendations, which also said that self-examinations were unnecessary, don’t apply to women who carry a high risk for breast cancer. Those women should talk to their doctors about when to get screening, the panel said.

The new guidelines, published yesterday in the Annals of Internal Medicine, pit the task force against the American Cancer Society, which insisted doctors should still advise women to undergo routine annual screening starting at age 40. About 64 percent of women ages 40 to 49 had an X-ray of their breasts during the past two years, the panel’s report said.

“This is not a blanket recommendation not to worry until age 50,” said Diana Petitti, a disease epidemiologist at Arizona State University in Tempe, Arizona, and vice chair of the panel. “It’s a recommendation to have a discussion with your physician to better understand the trade-offs between starting exams now and starting later.”

Imaging machines for mammograms, and related supplies, are marketed by Fairfield, Connecticut-based General Electric Co., Bedford, Massachusetts-based Hologic Inc. and Munich-based Siemens AG.

Insurer Coverage

J. Leonard Lichtenfeld, the American Cancer Society’s deputy chief medical officer, said the panel’s guidelines may affect insurance payouts. ‘Our hope is that insurers will not make any change in coverage,” Lichtenfeld said.

WellPoint Inc., the top U.S. health insurer by enrollment with 34 million members, pays for annual mammograms for women age 40 in the majority of its health plans. The Indianapolis- based company periodically reviews its reimbursement policies and “doesn’t adhere to any one source” for guidance, said Jill Becher, a company spokeswoman in Milwaukee.

The new guidelines, if widely adopted by physicians and insurers, could reduce the number of U.S. mammogram screenings by 58 percent, from the current 37.2 million annually to 15.6 million under a “worst-case scenario,” Junaid Husain, a Boston-based analyst at Soleil Securities, wrote in a note to investors today.

Detecting Cancer

Mammograms, self-breast examinations, and doctor’s exams are the three main forms of detecting breast cancer. The task force said there was no evidence that self-exams reduce breast- cancer deaths, and insufficient information exists to recommend that doctors do routine physical exams.

The mammograms are used to check for breast cancer in women who have no signs or symptoms of the disease, and also to check for breast cancer after a lump or other signs of cancer have been found, according to the National Cancer Institute.

Breast cancer is the second-leading cause of cancer-related deaths among U.S. women, after lung cancer, killing 40,480 women in 2008, according to the task force report.

The task force analyzed published research and developed computer-simulation models to evaluate the likely health outcomes if mammograms were begun at certain ages and done every one or two years.

Deaths, False Positive Tests

The study confirmed earlier research that women who have mammograms die less frequently of breast cancer than those who don’t have the tests. About two deaths per 1,000 women are averted if women begin annual screenings rather than exams every two years starting at age 40, the task force estimated.

It also estimated that women who begin getting mammograms at 40 will have about 60 percent more false positive results per 1,000 exams than women who start screenings at age 50. A false positive, in which an abnormality is seen that proves not to be cancer, typically leads to additional screenings and tissue biopsies, the panel’s researchers said.

The cancer society challenged the reliability of the task force study’s methods.

“We are reluctant to recommend changing a proven program that has helped to save lives,” Lichtenfeld said. The society questions whether the task’s force computer modeling “is sufficiently sophisticated and accurate enough,” he said.

High-Risk Women

The recommendations aren’t intended for women older than 40 who have a higher risk for breast cancer. Increased risk can come from having a gene mutation linked to breast cancer or having been exposed often to chest radiation, which can raise the probability of breast cancer.

The task force said it didn’t make recommendations for these higher-risk groups because it lacked sufficient data to know the benefits of more frequent screening tests.

Women’s health groups varied in their responses to the new guidelines.

Susan G. Komen for the Cure, the Dallas-based breast cancer advocacy group, said it won’t change its recommendation that women ages 40 to 49 get annual mammograms. “We would not want to see a change in policy or reimbursement for screening mammography at this time,” said Eric Winer, the group’s chief scientific adviser, in a statement.

The task force’s recommendations were applauded by the National Breast Cancer Coalition, a Washington-based advocacy group, which said the guidelines support its position.

‘Deserve the Truth’

“Women deserve the truth even when it is complicated,” said Fran Visco, the coalition’s president, in a statement. “They can accept it.”

The American College of Obstetricians and Gynecologists rejected the task force’s recommendations, maintaining its guidelines that women in their 40s be screened every one to two years and women age 50 and older get annual exams, according to a statement issued by the group on Monday.

Researchers and physicians know that results from the X- rays aren’t as reliable in younger women as in older women. Women in their 40s typically have denser breast tissue, making it more difficult for technicians to determine if an image is normal or cancerous.

After women enter menopause, typically about age 50, the breast tissue becomes less dense and more fat, and the X-rays can be more accurately interpreted, said Susan Love, president and medical director of the Dr. Susan Love Research Foundation in Santa Monica, California.

‘Long Overdue’

The panel’s suggestions for women ages 40 to 49 are “long overdue,” said Love in a telephone interview. “Most countries in the world do not do mammography screening until age 50.”

“There is a lot of anxiety created when someone tells you that there is something that showed up in a test,” said Karla Kerlikowske, an epidemiologist at the University of California, San Francisco, Medical Center who wrote an editorial accompanying the task force report.

Subsequent exams expose women to more radiation, and although biopsies are “low risk,” some patients develop infections or experience pain and bruises, she said.

Screening women ages 50 to 74 every two years “achieves most of the benefit of annual screening with less harm,” the task force said. Now women in the older age group get a mammogram, on average, every 14 months, according to the report.

In forming its guidelines, the task force’s “biggest concern” was that women would be confused by conflicting advice from health experts or wrongly interpret the panel’s message as a blanket recommendation for those ages 40 to 49 to forego screening until they turn 50, Petitti said.

Risks, Preferences

Instead, decisions by women younger than 50 and their doctors should be based on “the risk for breast cancer and preferences about the benefits and harms” the task force wrote in the study.

Although the recommendations are “very clear and thoughtful,” women are likely to be confused by the different advice of health experts, Kerlikowske said.

It may be difficult to persuade many women in their 40s who have been told by their doctors for years that annual screenings are beneficial to accept the panel’s recommendations, said the cancer society’s Lichtenfeld.

“The task force is saying you can get 70 percent of the benefit if you get a mammogram every two years compared with every year,” Lichtenfeld said. “There will be women who say, ‘I want 100 percent of the benefit.’”

Source: Bloomberg

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Vermont leads the nation in the delivery of its health care, while Mississippi is rated the worst, according to a non-partisan study that compares all 50 states and the District of Columbia.

Vermont, Hawaii, Iowa, Minnesota, Maine and New Hampshire ranked 1 to 5 in 38 indicators of health care.

At the bottom were Mississippi, along with Oklahoma, Louisiana, Arkansas, Nevada and Texas.

The Commonwealth Fund Commission’s “Scorecard on Health System Performance,” rated the states on access, quality, costs and health outcomes in a follow up to their 2007 report.

Overall, the states which did best on the Commonwealth scorecard were in New England and the upper Midwest, and the worst states were in the South.

Vermont, with only 640,000 residents, has nearly universal health care coverage with 93 percent insured. Its innovative “Blue Print for Health” focuses on prevention of chronic diseases.

“We’re small. There are 19 cities larger than the state of Vermont,” said Susan Besio, director for health care reform and Medicaid for Vermont.

“But I believe there is something unique about Vermont in terms of its culture,” she told ABCNews.com. “We want to take care of each other and we are a healthy state.”

In Mississippi, however, about 20 percent are uninsured despite having some of the highest rates of hypertension, diabetes and asthma.

According to the report, only 35.7 percent of adults 50 or over in Mississippi receive recommended screening and preventive care.

“When you compare Mississippi on almost any socio-economic profile, we are a struggling population that has a large percentage of low-income individuals, high unemployment rates, low rate of education,” said Robert Pugh, director of the Mississippi Primary Health Care Association.

The scorecard “paints a picture of health care systems under stress, with deteriorating health insurance coverage for adults and rising health care costs,” according to co-author Cathy Schoen, who is senior vice president of the commission.

“Where you live matters for access, quality of care and whether you live a long and healthy life. These wide and persistent gaps among states highlight the need for national reforms and federal action to support states.”

For example, 32 percent of working-age adults in Texas are uninsured, compared to only 7 percent in Massachusetts in the most recent survey.

“It’s very hard to have a high performing health care system and hospitals that do well for everyone if you have a high rate of uninsured in the state,” said Schoen.

In 1999-00, there were only two states with 23 percent or more of adults uninsured. But by 2007-2008 there were nine.

Children fared much better, due in large part to the Children’s Health Insurance Program (CHIP) under Medicaid. The number of states with 16 percent or more of children uninsured dropped from nine to three during the same time period.

Other findings of the report were that in a, costs rose and quality improved in areas where outcomes were reported to the public.

Vermont’s ‘Blue Print For Health’ A Model

The Green Mountain state was cited for its model “Blue Print” program. Launched by Republican Gov. Jim Douglas, it covers everything from teaching children healthy eating to helping seniors stay in their homes rather than going to costly nursing homes.

“You betcha, I feel good about the reforms we put in place,” Douglas told ABCNews.com. “It’s centered on quality and containing costs. Care shouldn’t start in the emergency room.”

All Vermonters are encouraged to have yearly exams and adults are notified when they are due for check-ups.

Douglas talks to children about “getting off the couch” and set an example just this week by joining elementary students on a walk to school.

With the second oldest population in the nation, Vermont subsizes care for seniors and the disabled to defray the costs of home care. Nursing home beds were reduced by 200 last year.

In one pilot program, electronic medical records can avert expensive tests like MRIs and x-rays. One emergency room doctor seeing a woman with stomach pains discovered in her online medication history that she had not filled her prescription for ulcer medicine.

“It takes time and so a lot of the fruits come from years of work and planning and cooperation,” said Douglas.

Health Care Affects a State’s Economy

But Mississippi, with the highest infant mortality and low birth rates in the nation, makes access to these Medicaid programs more difficult, according to Roy Mitchell, director of the Mississippi Health Advocacy Program (MHAP).

“I am not at all surprised we were 51st on the list,” he told ABCNews.com. “We are last on several health indicators. Our policy makers work hard at being last.”

Despite one of the highest matches of federal to state dollars in Medicaid funding, the state mandates “face-to-face” eligibility, requiring all new applicants and those reapplying for benefits to come in for an interview.

“As a direct result, 65,000 children have fallen off the rolls,” Mitchell said.

“Mississippi does virtually no outreach at all. They don’t publish where these face to face stations are and what times,” he said. “It’s a bureaucratic maze even to find out where to go. And when they get there they don’t have a certain document.”

Of those, about 77 percent would be eligible, he said. “It’s touted as fraud prevention.”

These disparities between the highest and lowest ranked states could be alleviated with national reform, according to Commonwealth.

The report emphasizes the need for insurance reform that rewards good outcomes, payment reform with an emphasis on prevention and advanced information systems that travel with the patient from physician to physician, saving time, money and preventing errors.

“What the scorecard is showing is that we have a system under stress, no matter where we live,” said co-author Schoen. “The costs are rising more than people’s incomes. We need to act.”

Schoen said she has hope for reform. “There is real leadership and people are taking reform seriously.”

Source: ABC News

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