Health Council Answers Screening Questions

The Bermuda Health Council [BHeC] is providing information regarding recent concerns about screening mammography guidelines in order to answer the most frequently asked questions surrounding the changes to screening mammography guidelines.

A Health Council spokesperson said, “The goal to adopt international screening guidelines in Bermuda emerged through a Health Council collaboration with local physician leaders: the Bermuda Medical Doctors’ Association [BMDA], the Bermuda Medical Council [BMC], the Bermuda Hospitals Board [BHB], and the Ministry of Health, Seniors and Environment.

“The group was led by the desire to provide a better standard of care by instituting guidelines for healthcare in Bermuda based on the most up to date scientific evidence base.

“The work was grounded on the principles of the US “Choosing Wisely” and the UK’s “Too much medicine” sister campaigns of medical associations. These are concerned with improving the standards of medical care by delivering the right care at the right time. Local physician leaders assessed screening guidelines available in the US, Canada and the UK.

“Ultimately, the US Preventive Services Task Force [USPSTF] guidelines were considered the best option for Bermuda as they are scientifically rigorous, highly regarded internationally, culturally appropriate, and publicly available .

“International guidelines on screening mammography have long adopted a more conservative standard than Bermuda has used, and each country has seen similar mortality reductions across the board.

“Given the extensive evidence base regarding benefits and harms, the group recommended that the Minister adopt the standard of personalised decisions for under 50s and biennial screening for women aged 50-74 years.”

Below are some of the most frequently asked questions regarding the adoption of the screening mammography guidelines, and the replies provided by BHeC.

If I am under 50 and want to have a mammogram, will I have to pay for it myself?

“As with all medical interventions, you should discuss it with your medical doctor first. Together you’ll make a decision that is right for you. If your doctor does not see clinical reasons for you to have a screening mammogram, you could pay for it yourself, as you would for any medically unnecessary procedure.”

“If your doctor sees merit in referring you, your insurance will cover it by law.”

What harm can mammograms really do? My mom has been having them since she was 40 without any signs of problems.

“It exposes women to low levels of radiation which, over time, can be a greater risk in itself. In addition, intensive screening results in finding a multitude of minor and innocuous abnormalities that are then investigated and treated more invasively, though they were never going to become serious.

“This is known as over-diagnosis, and it can cause harm to women, as well as contribute to unnecessary psychological distress.”

Why wouldn’t you screen earlier? I thought if you screened earlier you would catch it sooner and save money and lives by reducing the need for invasive medical interventions.

“Early detection is great when it’s picking up real problems. The trouble with overly-intensive screening is that it largely detects things that are not problematic or risky. We know they are not because the largest studies available show that detecting such small anomalies does not result in reduced deaths.

“It is better to properly screen populations at risk, than to over-diagnose groups with no known risks.”

If the American College of Radiologists does not support these guidelines, why are we considering implementing them?

“Most international bodies support the ‘50 plus’ guideline – some are more conservative. Organizations representing specialists have a perspective which reflects their unique experience. It’s better to be guided by independent agencies with no vested interests in a particular technology or modality.

“These guidelines are supported by multiple specialities and experts whose focus is on prevention and on the wider perspective which balances risk of over-diagnosis with the benefits of a procedure.”

Isn’t changing the age to 50 for screenings just the Government implementing a cost-saving measure?

“This is not a cost-saving measure. The guideline was recommended by local medical leaders concerned with healthcare quality and the benefits and risks of medical interventions. In fact, data shows that too many women aged 50 to 74 are neglecting screening at present, and more effort has to be made to encourage this group.

“The Government will not see any material savings from the shift.”

6. Do any oncologists support these guidelines?

“Bermuda’s two oncologists support the recommendation. In addition, the ’50-plus’ guideline is supported by the Royal College of Physicians and Surgeons of Canada, the Canadian Medical Association, the Canadian Task Force on Preventive Health Care, the Canadian Cancer Society, the National Clinical Guidelines Centre [UK], the National Institute for Health and Care Excellence [UK], and various medical Royal Colleges.

“The guideline is also recommended by the Nordic Cochrane Centre, an independent research centre which has published more research on mammography screening than any other independent institution; you can see their leaflet online [PDF here].”

Are any other countries implementing these guidelines? The US is not always right.

“Canada, Australia and England all have similar guidelines recommending screening from age 50. Other European countries do so also. The more progressive are considering abandoning some screening programmes that have not proven to improve health or reduce deaths.

“For example, a large Danish study found that two regions had similar drops in breast cancer mortality over the same period despite one having no screening programme at all. The mortality drops were due to improved treatment and access to it.”

Who is the task force that reviewed these guidelines? Do any of them have expertise in cancer care or breast cancer screening?

“The U.S. Preventive Services Task Force is comprised of scientists and medical experts on prevention. Task Force scientific analyses and interpretations were conducted on research conducted by various experts, including cancer researchers.

“The Task Force is made up of 16 independent members who are nationally recognized experts in prevention, evidence-based medicine, and primary care, with expertise including family medicine, internal medicine, obstetrics and gynaecology.

“Locally the guidelines were recommended by physician leaders: the then President of the Bermuda Medical Doctors’ Association [BMDA], the Chief of Staff of the Bermuda Hospitals Board [BHB], and the Chief Medical Officer.”

The US Congress has not even accepted these guidelines so why should we?

“Medical recommendations based on scientific evidence are independent of political decisions. The guideline to screen over 50s may be under political scrutiny in the US, but it is widely accepted in Canada, Australia, England and other European countries.

“Be aware that the political realm can be strongly influenced by special-interest groups and lobbyists whose primary concern is not the health of the population. Bermuda needn’t be restrained by political decisions in the US.

“It is better that we be guided by the scientific evidence. Anyone can read the evidence, for example here.”

With the high incidence of breast cancers in Bermuda, and a population very different from that in the US, when will we as a country start allowing local health statistics to drive our local health policy?

“It’s hard for small populations to produce large enough samples to yield scientifically valid results. There were less than 70 breast cancers diagnosed in Bermuda in 2014. We cannot make scientifically accurate recommendations from a sample size this small. However, the studies available on cancer in African Americans have not found statistical evidence that earlier screening reduces mortality.

“Despite similar screening rates, black women are less likely to be diagnosed with breast cancer than white women; yet are more likely to die of breast cancer. The reasons are believed to be access to treatment and the types of cancer. It is important to understand that earlier diagnosis has not been shown to result in a reduction in mortality from breast cancer. The improvements in survival rates for breast cancer have been attributed primarily to improvements in treatment modalities.

“The only large-scale cancer study publicly available in Bermuda is here [PDF]. However, in the coming years, efforts will continue to track local trends, the prior history and outcomes of our small population of cancer patients.

“This will help to shed more light on the local situation. In the meantime, we must rely on the findings and recommendations from larger jurisdictions whose studies have scientific and statistical validity.”

#BermudaHealthCouncil #Health

Category: All