Minister: Recommendation Was ‘Misinterpreted’

“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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