Q&A: USPSTF Chair Kirsten Bibbins-Domingo on the task force's cancer screening recommendations

The U.S. Preventive Services Task Force (USPSTF) is an independent panel of national healthcare experts funded by the United States Department of Health and Human Services. The task force issues recommendations about “clinical preventive services such as screenings, counseling services, and preventive medications,” and its recommendations for breast cancer screening and colorectal cancer screening have both made headlines in 2016.

Kirsten Bibbins-Domingo, PhD, MD, professor of medicine, epidemiology and biostatistics at the University of California, San Francisco, has been chair of the USPSTF since March. She spoke with Radiology Business about several topics, providing insight on how the task force’s recommendations are developed, how members are selected and more.

Radiology Business: Some radiologists, societies and even politicians have spoken out against the most recent USPSTF breast cancer screening recommendations, because biennial mammograms for women ages 40 to 49 were given a “C” rating and biennial mammograms were recommended for women ages 50 to 74 as opposed to annual mammograms. What is the task force’s reaction to these negative opinions?

Kirsten Bibbins-Domingo, PhD, MD: Breast cancer is a serious condition, and, as primary care clinicians and researchers, the task force shares the public’s concern about women’s health. Our dedication to the health of all Americans is why we issue and continue to update our recommendations to reflect the most current evidence. With regards to screening for breast cancer, we recommend that women between the ages of 50 and 74 get screened every two years. Women in this age range benefit most from screening mammography, and the evidence showed that women get the best balance of benefit to harm when screening is done every two years.  

Beginning mammography in the forties can help women reduce their risk of dying from breast cancer, but the likelihood of benefit is less, and there are potential harms. Our “C” recommendation for women in their 40s is a recommendation in favor of screening, and we recommend that women in this age range talk with their doctors about the potential benefits and harms so that they can make an informed choice together.

While we know that there are varying approaches and opinions about preventive health care, it is important to recognize the emerging convergence among groups who have recently issued evidence-based guidelines. It is important for patients and clinicians to understand the areas of agreement and for additional studies to address the remaining evidence gaps in the science of breast cancer screening.

Is there a misconception that leads a lot of the disagreement over the breast cancer screening recommendations?

There are two common misconceptions in our guidelines. Our “C” recommendation for women in their for 40s s is not a recommendation against screening. This is a recommendation in favor of screening that recognizes that beginning screening in the 40s has an important net benefit, but that the likelihood of benefit is small and screening carries with it some potential harms. Women should be empowered with the information about both benefits and harms and, together with their doctors, make the decision that's right for them.  

Similarly, our recommendations focus on areas where there are enough high quality studies for us to have certainty in our assessment. When we don't have enough evidence, we issue an “I” statement. Again, this is not a recommendation against screening, but rather a call for more research. In the absence of certain evidence for or against screening (as exists for women 75 and older), doctors and patients must use their best judgment regarding screening.

What is the USPSTF’s reaction when it sees the government including provisions in bills that delay implementation of USPSTF recommendations? What kind of impact do such delays have on patients throughout the U.S.?

The task force does not make recommendations for or against insurance coverage. Insurance coverage is determined by lawmakers, regulators and insurance companies. In the case of mammography, lawmakers exercised their ability to assure coverage for women in their 40s—as well as older women—who have private insurance will not have a co-pay for their screening mammograms. We hope that all women and their doctors will review our recommendations, which provide the best available information about the current science, and be empowered with that information to make informed decisions about their health and healthcare.

When the USPSTF recently released its final colorectal cancer screening recommendations, it removed the terms “recommended” and “alternative” in regards to screening options such as CT colonography. Why was this change made?

The task force determined that the terms were causing confusion for clinicians and patients, and were distracting people from the most important message: Colorectal cancer screening works and not enough people are getting screened. Many test are supported by evidence and the most important test is the one that patients actually complete to assure they are screened.

How does the USPSTF develop its recommendations?

To ensure scientific accuracy, the USPSTF follows a rigorous process for gathering and reviewing evidence, developing recommendations and engaging specialists to develop and review its work. Task force members meet in person three times per year, and in between meetings, they continue working to develop and refine their recommendation statements via regular conference calls and email communication.

You can learn more about this process on our website.

How are USPSTF members chosen?

New members are selected by the director of the Agency for Healthcare Research and Quality (AHRQ) in consultation with task force leadership. Members are chosen based on their qualifications and the current needs of the task force for particular areas of expertise. Overall, members represent an array of experts in primary care and preventive health-related disciplines, including internal medicine, family medicine, behavioral medicine, pediatrics, obstetrics/gynecology and nursing.

Is there anything else the USPSTF would like to discuss or comment on?

The task force just released a final recommendation statement recommending screening adults age 50 to 75 for colorectal cancer. Colorectal cancer is the second leading cause of death from cancer in the U.S. Evidence shows that colorectal cancer screening is very effective, but not enough people are getting screened. It is clear that adults ages 50 to 75 years will substantially benefit from getting screened, but about one-third of people in this age group have never done so. The task force would like people to know that screening works to reduce the risk of dying from colorectal cancer, and it is important that people who are 50 to 75 years old talk to their doctor about getting screened.  

This text was edited for clarity and length.