Minister: Recommendation Was ‘Misinterpreted’

June 1, 2015

“Regrettably, a health screening recommendation intended to improve the health of women by reducing their exposure to the risks of ‘over diagnosis’ has been misinterpreted,” Minister of Health, Seniors and Environment Jeanne Atherden said in the House of Assembly on Friday [May 29].

Minister Atherden said, “This Government is not introducing legislation telling Bermudian women they can only have a mammogram once every two years and it is misleading to suggest that having mammograms once every two years will cause death by delay.

“The Bill seeks to ensure the coverage for Bermuda’s minimum health insurance package, the Standard Hospital Benefit [SHB], is grounded on evidence-based medicine, and in line with international best practice, with respect to screening mammography.

“Women with a family history or other risk factors will still be covered for testing with a physician referral at any age. This amendment seeks to ensure that women obtain physician input in the decision to use this technology in young ages where the science indicates that the benefits do not outweigh the risks.

“I wish to make it clear that any woman with an immediate family member with the disease, dense breasts or who have used hormones after menopause for five years, plus other risk factors known to the patient and her physician, will have full access to all mammography coverage necessary, as they do now.

“The decision of when to screen or not with mammography should be made by a woman and her physician, after consultation together.

“This Government will continue to provide the best possible range of care options under the Standard Health Benefit at affordable rates. We believe in healthy people in healthy communities.”

Minister Atherden’s full statement follows below:

Mr. Speaker, Honourable Members will recall that in the course of last week’s session I indicated to this Honourable House and the public the variety of changes made to the Standard Hospital Benefit, soon to be called the Standard Health Benefit. In the course of that statement, Mr. Speaker, I indicated the following:

“Screening mammograms will be covered as SHB when they are in adherence with specific Clinical Guidelines. Mammography represents 30% of all diagnostic imaging costs in Bermuda. Currently, the health system follows the American College of Radiology guidelines for mammography which recommend annual screenings for all women aged over 40 years.

“A clinical review has proposed changing the Bermuda standard to follow the United States Preventive Services Task Force [USPSTF] Guidelines, which recommend biennial screening for healthy, asymptomatic women aged 50 to 74 years. Women with a family history or other risk factors will still be covered for testing with a physician referral.

“This will result in better use of scarce healthcare resources, while following best-practice international guidelines on screening. Accordingly, SHB coverage for screening mammograms will be required to adhere to the USPSTF guidelines.”

Mr. Speaker, regrettably, a health screening recommendation intended to improve the health of women by reducing their exposure to the risks of “over diagnosis” has been misinterpreted.

Mr. Speaker, this Government is not introducing legislation telling Bermudian women they can only have a mammogram once every two years and it is misleading to suggest that having mammograms once every two years will cause death by delay.

Mr. Speaker, the Bill which will eventually be taken up by this Honourable House, seeks to ensure the coverage for Bermuda’s minimum health insurance package – the Standard Hospital Benefit [SHB] is grounded on evidence-based medicine, and in line with international best practice, with respect to screening mammography.

Women with a family history or other risk factors will still be covered for testing with a physician referral at any age. This amendment seeks to ensure that women obtain physician input in the decision to use this technology in young ages where the science indicates that the benefits do not outweigh the risks.

Mr. Speaker, currently, the health system in Bermuda informally follows the American College of Radiology guidelines for mammography which recommend annual screenings for women aged over 40 years. A clinical review of various international guidelines from several countries has proposed changing the Bermuda standard to follow the United States Preventive Services Task Force [USPSTF] Guidelines which recommend that healthy, asymptomatic women aged 50 to 74 years be screened every two years.

The USPSTF Guidelines are recommendations which review, analyze, interpret and then report the evidence from a multitude of studies conducted by international subject experts.

Mr. Speaker, the recommendations are agreed upon using a robust methodology by a panel of esteemed physicians and researchers representing a variety of fields. The Task Group has a rigorous screening process to ensure the members have no substantial conflicts of interest which would bias their opinions. Although the members represent multiple disciplines, all scientific fields cannot be represented on the Task Force for practical purposes.

The Task Force is comprised of scientists and medical experts on prevention. The decisions are made purely on scientific analysis of the harms of over-diagnosis and the benefits of early detection. As in all aspects of science, there is never perfect consensus on any topic among even the experts; likewise there is variation in the opinions around screening mammography

Locally, Mr. Speaker, physician leaders from the Bermuda Medical Doctors Association, the Bermuda Medical Council, and the Bermuda Hospitals Board, support the recommendation in addition to the Bermuda Health Council. The USPSTF was identified as a reasonable set of guidelines for our health system as they are moderate in nature, falling somewhere between the recommendations of individual specialty groups in the USA [such as American College of Radiology] and the UK’s National Institute for Heath and Care Excellence [NICE] guidelines.

It is important to note again that unanimous agreement on a standard is not a realistic expectation. But the standard of evidence provided by international studies has produced international consensus on the benefits of starting screening at age 50.

Mr. Speaker, I wish to make it clear that any woman with an immediate family member with the disease, dense breasts or who have used hormones after menopause for five years, plus other risk factors known to the patient and her physician, will have full access to all mammography coverage necessary, as they do now.

The decision of when to screen or not with mammography should be made by a woman and her physician, after consultation together.

Starting screening mammography at 50 is recommended by leading international agencies and experts. Bermuda considered clinical guidelines from the US, the UK and Canada which ranged from annually from age 40 to every three years from age 50.

The decision to use the USPSTF guidelines was based on the fact that international studies have found that annual screening for women with no symptoms and no risk factors leads to over-diagnosis, which results in repeated exposure to low levels of radiation and unnecessary treatment. The guidelines are highly credible and based on extensive meta-analyses of international studies.

There is no local study to support the notion that Bermudians of African descent might benefit from earlier detection, and neither of our guest prevention experts [Dr. Welch or Dr. LeFevre], nor the physician representatives collaborating in support of adherence to USPSTF Guidelines, are aware of any study data that support improved outcomes and less harm from “over-diagnosis” in such a sub-population who are systematically screened earlier.

Mr. Speaker, it is critical to remember that these are screening procedures for women with no symptoms, no family history and no risk factors. Black women in Bermuda who do have a family history or specific risk factors will be referred for mammography by their physician and it will be covered under the standard health benefit.

The legislative change clearly states that it is covered outside the guideline if there is a physician referral. Any insured woman at any age with a family history or other risk factors known to the patient and her physician will have full access to all mammography coverage necessary, as they do now.

Mr. Speaker, I wish to assure Honorable Members and the public that I am personally committed to fostering a health care system that puts the needs of people first. The adoption of these guidelines is based on my belief that decisions about every aspect of a person’s health should be made between the individual and their doctor. I am keenly aware of, and sensitive to, the concern that arises when changes are made to what we might call an established practice.

This change is not proposed lightly but I advance it confident in the fact that science supports it, doctors will administer it in the best interests of their patients and above all that women will be in greater control of their health care decisions.

Mr. Speaker, it is not helpful to the cause of promoting health and wellness in the community for issues like this one to be the subject of distortion and manufactured media attention. Fear does not make for better medical decisions and the women of this community should feel empowered to make healthcare choices independent of politics and based solely on their individual consultation with their doctors. This Government will continue to provide the best possible range of care options under the Standard Health Benefit at affordable rates. We believe in healthy people in healthy communities.

Thank you, Mr. Speaker.

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Comments (21)

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  1. Unbelievable says:

    Oh look another week goes by and the OBA has to correct the PLP’s misinformation campaign.

    • Mockingjay says:

      That’s her interpretation, typical Surrogate spin.

      • jt says:

        Kunta…you are a surrogate and don’t even know it…or maybe you do.

      • Cow Polly says:

        She’ the minister – believe your comment relates back to you

  2. Shell says:

    What about the women who don’t meet the criteria?? I don’t believe there is any misunderstanding.

    Bottom line – if you are under 50′ and do NOT have a history of breast cancer or any other risk factors you will not be able to have a mammogram unless you pay for it yourself. SHB will not cover you.

    I agree, talk with your doctor but if he can’t feel a lump or justify the need for a mammogram then you will not be covered. I have no history of breast cancer in my family and no other risk factors. My lumps could not be felt and the only way to see them was via a mammogram. You have all seen my letter to the OBA members. Despite Mrs. Atherden’s continuous defense of what this amendment means I stil feel very strongly that a woman should have the right to choose whether she is willing to take the small risk of a mammogram or the larger risk of possibly finding out she has advanced breast cancer.

    My mother has been having mammograms since the age of 40. She is 70 years old now and healthier than me. The mammograms have not done her any harm that we know of.

    I remember my first mammogram. I was terrified and worried about the pain. Another woman came out rubbing her breasts and moaning about how awful it was. I was ready to bolt for the door! It was uncomfortable and I was nervous every time but I would choose a mammogram every time if it meant they could catch cancer if it appeared. Early detection makes a huge difference in your treatment and life expectancy.

    I would like to add that since I completed my treatments and had both breasts removed, I have also had to undergo physiotherapy for my right arm, I have had to have my ovaries and tubes removed, I now have to have bone density tests and most recently a bone scan. Catch breast cancer early enough and the costs involved in further treatments and follow ups may not be necessary.

    • Onion says:

      …or you can get your doctor to refer you.

      If you want to get a test done and your doctor doesn’t think you need it then I don’t think it’s out of line to expect you to pay for it.

      • Shell says:

        When I had my first mastectomy I asked my doctor if I should have a double mastectomy. He didn’t think I needed it. 1 year later I had cancer on the other side.

  3. “Misinterpreted.” I quote the Minister of Health, Seniors and Environment Jeanne Atherden speech made Friday May 29 2015.
    “Mr. Speaker, it is not helpful to the cause of promoting health and wellness in the community for issues like this one to be the subject of distortion and manufactured media attention. Fear does not make for better medical decisions and the women of this community should feel empowered to make healthcare choices independent of politics and based solely on their individual consultation with their doctors. This Government will continue to provide the best possible range of care options under the Standard Health Benefit at affordable rates. We believe in healthy people in healthy communities.”

    Thank you, Mr. Speaker. -(End of quote)

    (I want to thank the Minister for clarifying her stance…)

    • Rhonda says:

      Definition of intellectually lazy

      Do you think a majority of America (Bermudians) has become intellectually lazy?
      Meaning: Do they accept what their told more often than they critically examine the status quo?

      • aceboy says:

        We had 14 years of willful blindness, that much is for sure.

        How many fingers am I holding up?

    • clearasmud says:

      @Raymond you seem willing to accept anything a minister says as gospel but restating their comments do not make them any truer. If the minister has so much support for this approach from doctors and others then it would be better to hear from them directly. This issue is not as straight forward as the minister implies and still is being hotly debated in the US so whats the rush?

    • Back-in-the-day-girl says:

      there is no “misinterpretation” in the fact that if you are under the age of 50 with no indicators, symptoms or family history, you will not be covered for mammogram based on the current proposed legislation. I know of 20 women UNDER the age of 49 who, have been diagnosed with cancer – 12 of which did not have a family history or physical indications. If they had waited to 50, things may have progressed to the point that it would have been too late to treat.

  4. Jus' Askin' says:

    Typical OBA style, looking out for Big Business ;-)
    OBA, try Protecting Litte People for once :-D

    • Onion says:

      This will mean lower profits for doctors, insurance companies, and the Hospital.

      The losers here are big business.

      • Jus' Askin' says:

        The insurance companies are winning in this case m8

    • Zevon says:

      So you want higher insurance premiums? Ok, got it.

      • Jus' Askin' says:

        Higher premiums are coming anyway m8 :-D

  5. Real Talk (original) says:

    http://www.ktoo.org/2015/05/19/change-to-mammogram-guidelines-could-lead-to-coverage-shift/

    In her defense of the changes the Minister ignores the fact that the proposed guidelines are just that – proposed. The public consultation period still open and the proposed amended guidelines have not been adopted in the US for the same reason that they are being pushed back on here in Bermuda.

    There is valid public skepticism of the proposals and if one is going to tell the story, tell the whole story.

  6. Huh says:

    Yup lazy. There their history is, they’re not going anywhere.

  7. Lauren Furbert says:

    So as I understand this and correct me if I am wrong , the issue here is for women over 50. They are the ones who will be potentially screwed. They are the ones who if presumed healthy and not at risk will have no choice but to have only one mammogram every other year. Now I ask will their ins policies be reduced? After all they will not be claiming every year or is this as we see it a cost cutting measure because the amount of radiation received during this procedure is Miniscular and can’t be the reason for this major change. I wonder why Dr Kevin Hughes from the partners group has not been consulted! He has done extensive research on the Bermudian population regarding the high prevalence of breast cancer on our Island. I hear rhetoric about best practices …. Best for whom? Our island is a unique place ! Our gene pool is extremely concentrated and so diseases like cancers are are far more prevalent. And so I ask how con what’s best for Australia be what’s best for us … Seems like we are trying to fit a round peg into a square hole we need decisions made on our own unique demographics not what’s international best practice but what’s best for us. I don’t care who is in political power when lives are at stake. If you are not touched by this personally you can not begin to understand. I do know that cancer does not care about how old you are and if you are at risk or not I also know that most cancer is found through mammograms and that it may not be there this year but may be the next and if left undetected for a year the out come and treatment are are a whole lot different then early detection. There are no hard and fast rules for who is real ally at risk and it can struck when and who it wants. Right now is not the time to be laying with people’s lives . The economic position we all find ourselves in is very stressful and stress is a precursor to cancer growth. So please let’s stop the name calling and blame game. Let’s look at this legislation objectively and do the right thing for all women. I know a bit about this as I have walked this road !

    • Real Talk (original) says:

      Whilst all women should certainly be informed, I think the other issue here concerns women UNDER 50 who will no longer have annual mammograms covered by insurance unless their doctor orders it on the basis that they are “high risk”- at which point it might be too late.

      After drilling “early detection” into women’s heads we now appear to have a 180 which on the face of it looks to be about driving down the rising cost of healthcare versus what has long been established as best practice.