United States Preventive Services Task Force

Mark Masselli: This is Conversations on Health Care. I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Margaret, the United States Senate took a historical vote on
Saturday night allowing the health reform legislation to come to the floor of the
senate for debate, they will be starting the debate after the Thanksgiving recess.

Margaret Flinter: Well that’s something to be thankful for. Senator Reed needed
60 votes to make this happen and he got his 58 Democrats and 2 Independents
though not 1 Republican voted for the motion to proceed. Mark you went down
to Washington and heard the debate, tell us how this all unfolded.

Mark Masselli: As I sat in the Senate Balcony and listened to the debate the tone
was very personal and intense. The battleground had been drawn and it was
clearly partisan as the Republicans would not provide any votes. And they used
every emotional card they could laying their position out with Senate minority
leader Mitch McConnell would taunted the Democrats that the Democrats would
not be enticed by Republican mantra of just say no. A number of Democratic
Senators noted they have been saying no to reform for the past 100 years the
time was in hand to stand up and say yes to the health needs of our country, now
was the time to move the question when the historic vote finally came.
Connecticut Senator Chris Dodd was given the honor of presiding as President of
the Senate.

Margaret Flinter: It was high drama just as it was during the weeks leading up to
the vote. It wasn’t assured that Senator Reed would get those 60 votes that he
needed but late Friday the 2 votes in question Senator Lincoln from Arkansas
and Senator Landrieu from Louisiana agreed to allow a debate. Senator Lincoln
said it’s more important that we began this debate to improve our nation’s
healthcare system for all Americans than to just simply drop the issue and walk
away, but they were both clear to say this does not mean that they will approve
the final bill.

Mark Masselli: Up to now the Democrats have had history and timing on their
side with the super majority in the Senate and house a President willing to use
his political capital on this all important issue and a public ready to support health
reform.

Margaret Flinter: But new issues continue to arise and complicate the debate.
This week it was a surprise announcement by the United States Preventive
Services Task Force which came out with a set of controversial recommendations
on mammography. We will be discussing those in greater detail later on the
show, but in terms of the difficulty of assembling political support for health reform

the new recommendations along with the very challenging issues like abortion
coverage are cutting away a critical support from both Moderates and Liberals.

Mark Masselli: Challenging indeed and we will keep our eye on this as the
calendar moves forward. The Senate hopes to vote on this bill before the
Christmas recess and then goes to the House Senate Conference Committee to
reconcile the differences and then back to both chambers for final action, but it
looks like the President’s demand that we get all of this accomplished this year
will not be in the cards, we are clearly headed to 2010.

Margaret Flinter: And 2010 is right around the corner Mark, we will be keeping all
of this in focus, no pun intended.

Mark Masselli: Margaret I heard from a number of friends who were part of our
formation of our local free clinic, they listened to our story on the national free
clinic movement, they reminded me that what makes up a movement is the
incredible network of volunteers that are needed to be successful.

Margaret Flinter: Yeah and you really have to take your head up to the many
doctors, nurses, dentists, community activists who get engaged in helping out
their neighbors and their neighborhoods.

Mark Masselli: I know that you have been one of those volunteers here in
Connecticut with the mission of Mercy’s Dental Project.

Margaret Flinter: One of hundreds of volunteers and it made a huge impression
on me. You know we have a statewide dental mission of Mercy coming up in the
Spring of 2010 right here in Middletown.

Mark Masselli: You will have to let us know more about that as the date gets
closer.

Margaret Flinter: And I will be enlisting you as a volunteer. This week we are
going to take an in-depth look at new guidelines proposed by the United States
Preventive Services Task Force and publish in the annals of internal medicine.
The new recommendations say that most women should wait to start regular
breast cancer screening until 50 not 40 and that women between 50 and 74
should have mammograms less frequently. They also say doctor should stop
teaching women to examine their breasts on a regular basis according to the
guidelines.

Mark Masselli: The preventative service task force recommendation has caused
a real stir amongst women health advocates and many clinicians. It also is being
raised by some as an example of what direction the government might had if
health reform is passed but Margaret with those guidelines done by independent
health providers and in fact they were all appointed under the last administration.

Margaret Flinter: Mark, you are right on both accounts, evidence based care is
the bedrock of quality improvement and primary care providers count on these
recommendations based on the scientific review of the evidence. I think all sides
of the debate agree that we need independent mind reviews of the studies to
make these passionate assessments if such a thing is possible in healthcare of
what gives people the best outcomes, but this one touches the lives of so many
families, some of who feel that their are alive today because of early screening.

Mark Masselli: And one of them is Secretary Kathleen Sebelius in a release she
said that the task force does not set federal policy and they don’t determine what
services are covered by the Federal Government. Sebelius added then
American women should keep doing what they have been doing for years, talk to
your doctor about your individual history, ask questions and make decisions that
are right for you.

Margaret Flinter: And today we will be doing just that we will be speaking with Dr.
Kristen Zarfos a noted Breast Surgeon. She is widely recognized as a National
Advocate for Women’s Rights to Quality Healthcare, she spurred a national
movement to stop what she called drive-through mastectomies in the 1990s and
has continued to be a vocal advocate for women’s health.

Mark Masselli: We will also do an in-depth background report on the US
Preventative Service Task Force.

Margaret Flinter: No matter what the story, you can hear all of our shows on our
websites www.chcradio.com download the podcast or get transcripts of our show
and we have some interesting links for you on the folks we interview. And if you
have feedback on our show email us at [email protected] we would love
to hear from you.

Mark Masselli: And we should be letting our listeners know that starting next
week for a two-week period we will be participating in our radio stations fun drive
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from November 30 through Sunday night December 13 . Our goal is to help
raise $20,000 in these two weeks directly from our listeners through online
donation and calling pledges WESU which host this show is a college radio
station based in Middletown Connecticut. We will be talking to you more about
that next week.

Margaret Flinter: I know it seems to me I am always in the kitchen when these
appeals come and have some excuse for just not taking a moment. I will have to
work on an appeal that can motivate our listeners away from the smell of a hot
meal after a long day’s work.

Mark Masselli: Maybe we should promise to make dinner for our donors.

Margaret Flinter: Make a pledge and maybe you will get an invitation.

Mark Masselli: Now let’s go to our background report.

Margaret Flinter: When the US Preventive Services Task Force released its new
recommendations on screening for breast cancer last week it suddenly found
itself in the national spotlight. Reactions were swift and harsh from politicians,
advocacy groups, breast cancers survivors and their loved ones. Some
commentators said this is what we are afraid of with the public option, rationing,
denying the right to cancer screening. Others said this was a case of the
government meddling into personal healthcare, but most Americans had never
heard of the US Preventive Services Task Force. Who are they? Whom do they
work for? What is their charge and what’s the impact of their decisions? It calls
itself the leading independent panel of private sector experts in prevention and
primary care. The taskforce conducts rigorous impartial assessments of scientific
evidence for broad range of clinical preventative services including screening,
counseling and preventative medication and these recommendations are
considered the gold standard for clinical preventive services. Who sits on the US
Preventive Services Task Force? Each member is a private individual with
expertise in prevention, evidence based medicine and primary care. Taskforce
members include physicians, nurses and public health specialists from
universities and medical centers all across the United States. The taskforce
recommendations do not tell primary care clinicians what to do, but they do
provide clinicians with information about the evidence behind each
recommendation that allows clinicians to make decisions themselves. What is
unique and perhaps not well understood about the US Preventive Services Task
Force is that its goal is not to see a screen test, a counseling measure or a
medication as good or bad but to review all the evidence, estimate the magnitude
of the benefit and the harm for each preventative service and to issue a
recommendation. Those recommendations go from (a) strongly recommend to
(b) recommend (c) no recommendation for or against (d) recommend against or
(i) insufficient evidence to either recommend for or against and they have an
impact. Their recommendations have formed the basis of the clinical standards
from many medical quality review groups and professional societies, so why all of
the sudden the firestorm? It’s a combination of factors. First and foremost breast
cancer is the second cause of cancer deaths in women and that’s one of the
most feared diagnoses. Virtually all of us know someone or some family that has
suffered with and through a diagnosis of breast cancer. Early detection through
mammograms screening is widely believed to have led to earlier diagnosis and
reduce deaths among women found to have breast cancer. So this week’s really
strikes at the heart of the fear. Those women maybe denied a screening test that
might have save their lives. Second, the release comes at a time when health
reform is under consideration and the issue of a public option has become
synonymous with government run health insurance. Politicians and lay people
alike were quick to point out that this kind of rationing was exactly what the
country could expect if the government run public option came into being, but the

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recommendations themselves published in the November 17 Annals of Internal
Medicine, say something that has not been clearly heard. There are risks to
screening as well as benefits and those risks can be substantial and harmful.
Well what are the harms that could come from starting screening in earlier age?
The taskforce says there is harm, psychological harm, harm from unnecessary
imaging test and biopsies and women without cancer. Fear and inconvenience
due to false positive screening results, also largely are noticed in the
10.13_______ was their comment on special populations. The recommendation
statement does not apply to women over 40 who are at risk for breast cancer, by
virtue of a known underlying genetic mutation. It went on to say that the precise
age at which the benefits justify the potential harms is subjective as you take into
account the patient preferences. The taskforce also identifies further research
needs and gaps and say better understanding of certain facets of tumor biology
are needed. Particularly, how does age, race, breast density and other factors
predispose in women towards tumors with faster growth rates or greater fatality.
On Capitol Hill representative Debbie Wasserman Schultz of Florida Democrats
who used her battle with breast cancer to crusade for early detection and Marsha
Blackburn a Tennessee Republican tangled on whether the proposed senate
healthcare reform bill would deny mammograms to women between 40 and 50
years old. Representative Blackburn said it would, with government task forces
having the power to eject coverage now available to women but Ms. Wasserman
Schultz accused the Republicans of having politicized breast cancer contending
that the taskforce recommendations were just that recommendations and not
binding. One thing is for sure, as new research is done and more evidence is
analyzed recommendations change over time. The history of recommendations
for breast cancer screening alone shows many shifts and reversals as new
scientific information became available starting in 1963 with the first large trials of
the Impact of Mammography and up until last week’s announcement there have
been recommendations by the National Institutes of Health and National Cancer
Institute the American Cancer Society that went back and forth on the optimum
age to start mammogram screening. One thing is for sure Americans will be
hearing more about the US Preventative Services Task Force and its
recommendation in the coming weeks.

Mark Masselli: Today Conversations on Healthcare welcomes Dr. Kristen Zarfos.
Dr. Zarfos is the Director of the Comprehensive Breast Health Center at Saint
Francis Hospital and Medical Center and a nationally recognized advocate for
women’s health particularly breast health issues. Dr. Zarfos has received
numerous awards for her advocacy work and most notably took a stand against
what she termed drive-through mastectomies in the 1990s when managed care
organizations sought to limit hospital stays to a day or less for women post
mastectomy. In February 1997 she was introduced and asked to stand by
President Bill Clinton during a televised State of the Union address as he
acknowledged her work on this issue. She has testified before Congress on
breast cancer research and is active surgeon, lecturer and advocate. Welcome
Dr. Zarfos.

Kristen Zarfos: Well thank you it’s an honor to join you.

Margaret Flinter: Hello Dr. Zarfos and thanks for being with us. We have been
talking about the work of the United States Preventive Services Task Force which
until recently was a pretty unknown group of experts, but as a doctor and a
surgeon how have you used their recommendations in the past and have they
provided value for you and your patients?

Kristen Zarfos: Well I think that’s a good question Margaret because they have
been around for a while some people think that there is some connection
between healthcare reform and the task preventive force and there really isn’t.
They have been around for years. A few years ago they made recommendations
that women need not do breast self-examination. As someone who takes care of
women with breast problems you know that’s sort of an 13.39_______ to me
because we want women to be proactive in their health whether it’s just their
breast, looking for changes of skin or any part of their health, but the taskforce
we should understand what they do. They look at studies, they look at analysis
and how they arrive at why women should not check their breast was based on a
single study out of China which was a perspective study so they analyzed data
based on perspective studies, as there are studies of populations of people that
are assigned a taskforce to not do a task as opposed with retrospective study.
So not to deliver the self-exam issue as you but there are 13 studies that say
retrospectively if women examine their breast they might find a change, they find
a cancer earlier. But the taskforce really crunches numbers and it’s important to
understand in this current issue on mammography that they are analyzing what
studies have been done and superficially looking at the numbers on
mammography at what the benefits and the risks are to women.

Mark Masselli: Dr. Zarfos every patient is different but how do you talk to your
patients about whether and when to have screening test like mammography?

Kristen Zarfos: Well there is a excellent data and even the task preventive force
was very clear that women between 40 and 50, there is a 15% decrease in death
rate in women between 40 and 50 who have yearly mammogram. So the
taskforce has not said that there is no value at all, they are just saying on a
statistical basis based on computer models not scientific studies but computers
models that while mammograms do take lives and have decreased the death
rate 3.3% each year in this group of women between 40 and 50 for the last 12
years. So that’s not quite enough to outset all of the mammograms that women
have that show no cancer.

Margaret Flinter: You know it seems like a jump from there to say that the big
fear is that insurance companies will use the new recommendations to cut cost at
the expensive women’s health and wonder what your thoughts are on the history
there, hasn’t it been more of the case that insurance companies have been

forced to pay for services because the US Preventive Service Task Force gives
them that Type A or B strong recommendation?

Kristen Zarfos: Well yes and no but I think that also has to be framed in this year
where patients are fearful that not only healthcare reform but with their own
healthcare coverage, ever increasingly they pay more premium and have fewer
services delivered to them. In the world of MRIs which are very sophisticated
and very expensive studies that all women should not have for their breasts. We
find that many times insurance carrier will not cover MRIs even when they are
really indicated in women who are at increased risk. So if you have that
background fear and then new recommendations come out there is a great deal
of here. But it is also pretty clear that the taskforce recommendations are very
frequently embraced by primary care physicians and so patients are fearful that
their doctor may embrace these recommendations whether they are appropriate
for each person.

Mark Masselli: Dr. Zarfos you have made the point that women of different racial
and ethnic groups particularly African American women are diagnosed later and
have worst treatment outcomes than Caucasian women. Tell us about that and
how these recommendations might impact that group.

Kristen Zarfos: Mark I am glad you asked that question because in looking at
this data very carefully it makes me take pause at the credibility of how they are
analyzing the data and what I mean by that is 35% of black women developed
breast cancer before the age of 50, 35%. Now if you do the numbers think of the
significant impact on Afro-American women if they are not getting mammograms
when 35% of them are diagnosed very young. And you are quite right, women
who are diagnosed with breast cancer who are Black or Afro can tend to have a
higher grade, more aggressive tumor and even more reason why we should be
screening them even younger than 40. And so that is why I have to take pause
that you know when the taskforce looked at all of the data, that and I said earlier
superficial what I mean by that not in a shallow way from my standpoint but if
they ignore this very glary number, they perhaps shouldn’t qualify that, women
who are Black or Afro-American should be included in the 40 to 50 year group or
perhaps even younger. So that’s why I have to take pause if this group the
taskforce’s main issue or goal is to analyze data, they missed this piece which is
very, very important.

Margaret Flinter: Dr. Zarfos you hit it on ahead for me when you talked about
primary care providers using this data and when you read the study and the
report in the Annals of Internal Medicine you can’t help to think about this whole
issue of value based insurance and they are trying to say let us pay as much as
we need to for those things that have high value in healthcare and not pay or pay
less of the full amount for things with less value but it’s very hard to change our
beliefs even when the data suggests that, any thoughts on that?

Kristen Zarfos: Yeah I have, you have a point again having to do with looking at
any certain amount of data but not the depth of the data. If they are looking at
the overall cost I really wish in their analysis they would have looked at the
whole-day picture. If we are saying that it’s a “waste” and that’s not the word
they use but a waste of money to screen women between 40 and 50 before you
can make that analysis you have to look quite deeper, you have to look at what if
you delay a diagnosis in a woman between 40 or 50 because whether she is
Caucasian or black or of any ethnicity those cancers in premenopausal women
tend to be more aggressive and tend to be found later. And if we are going to do
a cost analysis and I am talking about a dollars and cents cost analysis then we
need to look at the cost of delaying a diagnosis with all the implications more of
surgery, perhaps a woman losing her breast, chemotherapy radiation time away
from work, time away from children if they are raising, time away from their
careers, time away from taking care of their parents which those women in the 40
year old group, 40 to 50 are doing. The other thing about value though Margaret
is what dollars and cents value can we place on life?

Mark Masselli: Dr. Zarfos you have been concerned for a long time with making
sure that all women have access to mammogram screenings nationally the
federal government has supported this through their breast and cervical cancer
early detection program which covers mammograms for uninsured and
underinsured low income women. Can you tell our listeners about that program
and how do you think that might be affected by the task force recommendations?

Kirsten Zarfos: Well Mark that’s a very insightful question. I hope that it doesn’t
impact the CDC program. The federal program allows for women of a certain
economic bracket if they don’t have insurance to have not only mammogram
screening but a gynecological examine a Pap smear and this is a very wonderful
way that the state and the federal government have collaborated to make sure
that underserved women can have access. Please understand nobody wants
healthcare reform better than I, nobody wants to see everybody covered because
I have seen too many women die from breast cancer because they didn’t know
about the CDC program and so I want to see everybody covered, but I also want
to make sure that we are able to give men and women the care that they deserve
based on the science not just willy-nilly or anecdotally. Evidence based medicine
is important to me but we are going to have to decide are we going to lose the
individual along in a statistical analysis that may not be an accurate statistical
analysis.

Margaret Flinter: So Dr. Zarfos in a local newspaper a political cartoon is
blogged the other day, the only people we should trust for health advice are
doctors and he said the very existence of the distinguished panel of experts
known as the US Preventive Services Task Force is disturbing I don’t like the
sound of it. If this bunch of yoyos are part of the infrastructure of healthcare
reform then I will drop my support, but as you know the people who serve on the
task force aren’t government employees or bureaucrats they are almost entirely

pretty distinguished expert doctors, nurses, researchers, public health people
with strong clinical backgrounds so what advice would we have for the preventive
services task force about how they communicate their message and the
information they provide to those of us in the field who need some guidance on
what the recommendations are?

Kirsten Zarfos: Well I do think that it would have been beneficial to have at least
an oncologist, a radiologist, perhaps a breast surgeon to help give a different
perspective on the data and that was missing. So perhaps the composition of
that panel on a particular issue should be rethought with each particular issue
that they look at going forward. So one really has to pause and say why would
you not pay for a mammogram because if you find a tiny cancer in women in this
age group you may elevate or prevent the patient at the age of 83 with a large
mass and facing not just the financial increased cost but all the more on ethical
issues if that patient has other health problems or dementia so there are some
big, big pictures big tweaks that need to be named how they crunch the data in to
their computer models to decide how to take care of people.

Mark Masselli: Dr. Zarfos thank you for being with us today.

Margaret Flinter: Thanks Dr. Zarfos.

Kirsten Zarfos: Thank you very much.

Mark Masselli: Each week, conversations highlight a bright idea about how to
make wellness a part of our communities into everyday lives. As we get ready to
celebrate Thanksgiving we give thanks for our health and the health of those we
love. If there is one thing we can do as individuals, communities and a nation to
improve health is to end tobacco dependency in our country. This week’s bright
idea is about one element in the comprehensive strategy to help people quit
smoking and tobacco use. Quitlines are the fastest growing smoking cessation
tool in the nation. Quitlines are telephone-based tobacco cessation services that
are proven to have real world effectiveness in helping smokers quit. Services
offered by Quitline include coaching and counseling, referrals, mailed materials,
web-based services and in some instances free medication such as nicotine
replacement therapy. Free public Quitlines exist in all 50 states, 1(800)
784-8669. In our home State of Connecticut the Quitline is supported by the
department of public health. Callers can phone Quitline 7 days a week almost 24
hours a day. Callers who are ready to quit smoking and are interested in further
telephone based services will receive up to 5 telephone counseling sessions.
Written materials are also sent to callers based on their readiness to quit. I called
the 800 Quitline, I was immediately offered help in English or Spanish. I spoke
with Ivy a Quitline counselor and told her about conversations on Healthcare and
bright ideas and asked if she had any message for our listeners. The Quitline is
working for a lot of people she said we are helping people everyday. This
Thanksgiving if you or someone at your holiday feast is a smoker think about a

new and hopefully one-time tradition. Before you dig into that Thanksgiving
dinner call the Quitline. Here’s that number again 1(800) 784-8669 now that’s a
bright idea.

Margaret Flinter: This is Conversations on Health Care. I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Margaret Flinter: Conversations on Health Care, broadcast from the Campus of
Wesleyan University at WESU, streaming live at Wesufm.org and brought to you
by the Community Health Center.