As happened following the controversial decisions of the United States Preventive Services Task Force on breast cancer screening, another controversy embroils the independent panel regarding prostate screening.
A report last month from the Wall Street Journal describes the recent decision of the United States Preventive Services Task Force, a 16-member panel of independent medical experts, to cancel a meeting set around Election Day.
One of the important items on the agenda would have been a vote on the utility of prostate cancer screening. The most recent recommendations (2008) state that prostate screening should not be conducted for men older than 75 years. For younger men, the evidence around the preferred screening test (the prostate specific antigen, PSA blood test) was inconclusive.
Dr. Kenneth Lin, now a former member of the USPSTF panel, implied that the cancellation of the November meeting was more than just a coincidence surrounding Election Day. Declaring that “politics trumped science,” Dr. Lin tendered his resignation from the USPSTF.
Why would the USPSTF avoid voting on the prostate cancer screening issue during the spotlight of Election Day? We only need to look back to the policy debates surrounding the passage of the Patient Protection and Affordable Care Act. In the new health reform law, the USPSTF was granted the power to require health insurers to cover any preventive services with a grade “A” or “B” rating.
The leaders of the USPSTF may have anticipated another controversy similar to the one surrounding their last mammography recommendation. As you may recall, the USPSTF revised its breast cancer screening recommendations in November 2009. Then, the scientific evidence recommended against routine screening mammography for women under age 50.
However, in response to constituents, an amendment by Senator Barbara Mikulski was added to the Patient Protection and Affordable Care Act. The amendment explicitly forbids using the USPSTF’s November 2009 breast cancer screening recommendation. The Mikulski amendment flexes its political muscle by directing all health insurers to cover mammography for women under age 50 even though the scientific evidence does not support this coverage decision.
It is no surprise that if the USPSTF anticipated another controversy around prostate cancer screening, the influential panel might postpone their vote to a less conspicuous time.
While the enhanced power granted to the USPSTF’s recommendations will likely help promote better health in the nation, the formerly obscure expert panel now faces public and political scrutiny over every critical decision it will make in the future.
PPACA essentially begins the transformation of the USPSTF into an entity similar to the National Institute for Health and Clinical Excellence (NICE), the organization tasked with determining coverage decisions for the British health care system. Medicine and therapies recommended by NICE are required to be covered under the British health system. USPSTF recommendations now carry this same authority in the United States. The unfortunate flip-side of the coin is that in cases where the USPSTF cannot make a cogent decision based on the available evidence (i.e. level “I” recommendations), insurers might elect to deny coverage altogether.
However, if politics is allowed to trump science, the concept of evidence-based health policy will never become reality.
Clinical guidelines and practice recommendations aid clinicians in standardizing care and in disseminating proven, effective treatments.
Where the evidence exists, we should follow it. Where the evidence is lacking, we should be aware.
Similarly, the practice of health policy should allow for positive evidence to be supported with legislation and regulation; negative evidence should direct decision-makers to avoid unnecessary (even if popular) decisions.
The danger lies in the unknown. Areas of health policy without a strong research base are subject to pure ideologic thinking. In other areas – such as medical malpractice, pay-for-performance, improved access to care – policy makers must trust the evidence and make difficult decisions that will move our health care system forward.
Cedric K. Dark, MD, MPH