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As you probably know by now, there’s been a huge debate raging since the U.S. Preventive Services Task Force’s early detection against breast cancer recommendations came out, and to help you make sense of those recommendations, we put together this interview with Dr. Bernadette Melnyk who is a task force member.
But before that interview gets started, I do want to let you know that if you are looking for tools to make the best health decisions possible, and quite frankly, that’s what EmpowHer’s goal is, to provide you the tools to make those health decisions. Well, then we’ve put together an overview interview featuring Dr. Bernadette Melnyk and also Dr. Jay Harness, and you can find that interview on the top of this page. Just look for the link that says EmpowHER's Overview on the U.S. Preventive Services Task Force's early detection against breast cancer recommendations, and in that interview they will address the two most important questions: How often you should perform a breast self-exam, and how often you should get your routine mammograms. The following, though, is the complete interview with Dr. Melnyk so you can understand the task force’s recommendations.
Dean Melnyk, is the U.S. Preventive Services Task Force saying that women shouldn’t get mammograms until they are 50 years old?
Dr. Bernadette Melnyk:
That is not what we are saying. Our most recent recommendation, Todd, is not again, not a recommendation against screening women in their 40s. It’s a recommendation against routine screening starting at age 40. What we need to understand though is, it is imperative that women talk to their provider, their physician, or their nurse practitioner about what their risks are for breast cancer.
Primary care providers are going to do a thorough history on that woman. If there is a risk for breast cancer, for instance, if a woman has breast cancer that runs in her family--her sister, her mother, her blood relatives--that woman would be at risk and would deserve to have a screen. What we are saying is not to start routine screening at age 40 for any woman who walks in the door of your office.
Todd Hartley:
Dean Melnyk, what makes routine mammogram so risky? I heard Dr. Jay Harness, the former President of the American Society of Breast Surgeons, saying that mammogram screening is not as risky as going through the metal detector at the airport. So what do we need to know?
Dr. Bernadette Melnyk:
Well, I think what people need to realize about over-screening when it is not necessary is that there are negatives such as false positives which result in unnecessary breast biopsies.
There’s also the anxiety that goes along with that. So again, the, you know, starting routine screening at age 40 has to be weighed against the harms of doing that, and again, if a woman has no risk factors for breast cancer those benefits are very, very small.
Todd Hartley:
Dr. Timothy Wilt, a member of the same task force that you sit on, told “Good Morning America” today that “this is not a recommendation to screen. It’s a recommendation to provide women with the facts. Our recommendations support an individualized decision-making process with the women so they have the knowledge about risks and benefits associated with their mammogram screening.”
So, it sounds like, from what you have told me, you agree with Dr. Wilt and what Dr. Wilt said this morning.
Dr. Bernadette Melnyk:
Absolutely. You know, anytime you practice in an evidence-based way, the clinician always takes into consideration the evidence-based guidelines for screenings, the best evidence from research, but you combine that with your clinical expertise as well as patient preferences and values to make the best decision for that individual person.
Todd Hartley:
Dean, the concern is that the task force’s recommendation now gives the insurance companies, well, the leeway to stop paying for mammograms for women under 50. What’s your reply to that?
Dr. Bernadette Melnyk:
My reply is that, again, if the mammogram is medically indicated, if the provider believes that that woman needs a mammogram because of risk factors that exist, I personally don’t think an insurer is going to deny covering the cost of that mammogram.
Todd Hartley:
What about breast self-exams? Now the report makes women feel like they shouldn’t be taught them, and self-exams do more harm than good. Can you clear this up for us?
Dr. Bernadette Melnyk:
Yeah, I think, you know, the latest evidence, again, does not recommend that teaching of self-breast exam because of the associated potential for harm; again, false positives, unnecessary biopsies, anxiety that it does cause women. We also have insufficient evidence at this point in time to make a recommendation for or against continuing clinical breast examination by healthcare providers.
Todd Hartley:
Dean Melnyk, was the government task force’s recommendation, was it motivated by political forces interested in passing the healthcare reform bill, and I am hearing suspicions about that. Is that accurate?
Dr. Bernadette Melnyk:
Absolutely not. I think the public, and this is another area that has been misperceived in the media is that the United States Preventive Services Task Force is an independent panel of the experts in primary care, in research, in behavioral science. So, we are not, we are not a government task force, and people keep confusing that. So there is no pressure on our end coming from the government in terms of our particular decisions. We are acting as experts in the field, as primary care providers as well, making the best evidence-informed decisions for the health of the public and primary care that we possibly can make.
Todd Hartley:
What do you say to breast cancer experts upset that the 16 members of the U.S. Preventive Services Task Force making these recommendations that none of them are oncologists or breast surgeons?
Dr. Bernadette Melnyk:
What I say is we do have experts in breast cancer, in cancer screening on the United States Preventive Services Task Force. So, although they may not be, per se, oncologists, they are experts in cancer screening.
Todd Hartley:
One thing I don’t think you and I discussed in this interview is, could you give us an overview on what type of thoughtfulness and overview goes into coming out with a recommendation? Give us kind of an inside view on how these recommendations come about.
Dr. Bernadette Melnyk:
Sure. The Agency for Healthcare Research and Quality, which is under the Health and Human Services, they actually fund so many evidence-based practice centers across the United States. Those centers are charged with doing systematic reviews of evidence in the selected topic areas that are under the task force’s designation.
So, what they do is, Todd, they go out, they collect all the studies that have been done in the area, they judge the quality of those studies, they synthesize the study, they bring that very thorough systematic review of those studies back to the United States Preventive Services Task Force.
We then go through a very rigorous process to review all of those studies ourselves. We critically appraise that evidence for its worth, you know, its validity, its reliability, and have very detailed, thoughtful discussions about that data and then, based on that, we come up with our recommendations from a very rigorous process of critical appraisal of the study.
Todd Hartley:
Dean Melnyk, did you and your fellow members of the U.S. Preventive Services Task Force, did you guys have any idea of the amount of uproar and anger that this recommendation would cause?
Dr. Bernadette Melnyk:
I really believed that, I believed that we would get a response to this change in recommendation, Todd, because again, this is a very emotional topic, and so when you talk to women who were diagnosed with breast cancer in their 40s, it’s going to raise people’s emotions.
It’s a very, very sensitive subject, but again, I really want to impress that, you know, our recommendation is based on very rigorous review of the recent studies that came out. I’ll give you an example--hormone replacement therapy, for example--look what we were doing with routine, pretty routine implementation of hormone replacement until another big clinical trial came out that really showed the negative consequences of the hormone replacement therapy. So people stopped that particular practice.
You know, we have to continue looking at and critically appraising new evidence that comes out and factor that new evidence into the older evidence that exists in making recommendations for practice change.
Todd Hartley:
Well, she is Dean Bernadette Melnyk. She is a member of the U.S. Preventive Services Task Force. Dean Melnyk, thank you so much for giving us an inside look at the recommendation, the research that went into it, and a thoughtful reply to a lot of the assumptions that are going around.