Before the Senate Committee on Appropriations
Subcommittee on Labor, Health and Human Services
Committee on Health, Education, Labor, and Pensions
Subcommittee on Public Health
Submitted by the Agency for Healthcare Research
Hearing on Mammography Screening
February 28, 2002
The Agency for Healthcare Research and Quality (AHRQ)
respectfully submits the following testimony on the effectiveness
of screening mammography for the record.
Today’s hearing is very timely in light of the recommendation
from the U.S. Preventive Services Task Force (USPSTF)
released last week on February 21, 2002, by HHS Secretary
Tommy G. Thompson. The USPSTF is a leading independent
panel of private-sector experts in prevention and primary
care sponsored by AHRQ that conducts rigorous, impartial
assessments of scientific evidence for a broad range of
preventive services. In its new recommendation, the USPSTF
endorsed screening mammography every 1-2 years for women
ages 40 and over.
AHRQ’s mission is to support research designed to improve
the outcomes and quality of health care, reduce its costs,
address patient safety and medical errors, and broaden
access to effective services. The research sponsored,
conducted, and disseminated by AHRQ provides information
that helps people make better decisions about health care.
With this mission, AHRQ-funded research activities provide
meaningful, evidence-based information on screening mammography
to women and their clinicians. The Agency does this in
three ways: first, supporting research that informs the
quality of mammography and interpretation of mammograms;
second, supporting a review of the up-to-date evidence
on mammography screening by the U.S. Preventive Services
Task Force (USPSTF); and third, developing evidence-based
materials for patients and clinicians.
Screening mammography is an important tool for reducing
deaths from breast cancer in women 40 and older. However,
it is not a perfect tool. Because it is not as specific
a test as it could be, false positives can occur which
often require repeat screening and/or biopsies. This can
cause significant anxiety among patients and their families,
as well as unnecessary health care expenditures. In addition,
problems with mammogram interpretation and communication
of results to patients can result in cancers that are
missed and treatment that is delayed.
As a result, the effectiveness and usefulness of mammography
have been the subject of controversy for many years. AHRQ,
along with other agencies of the Department of Health
and Human Services, have worked to build the foundation
of evidence for the effectiveness of mammography and to
ensure that patients have access to high quality screening.
One of AHRQ’s earliest activities in this area was the
development of a clinical practice guideline on how to
identify the elements of high quality mammography screening.
The guideline, developed in 1994 by an independent panel
sponsored by AHRQ’s predecessor, the Agency for Health
Care Policy and Research, was entitled Quality Determinants
of Mammography. The multidisciplinary panel that developed
the guideline comprised radiologists, radiologic technologists,
medical physicists, family practice physicians, a nurse,
an obstetrician-gynecologist, a surgeon, a pathologist,
an internist/oncologist, and consumer representatives.
Many of these panel members also served on the original
Food and Drug Administration (FDA) National Mammography
Quality Assurance Advisory Committee.
The guideline provided information to clinicians on providing
high quality mammography services and also gave patients
information on how to determine the quality of the mammography
services the received.
It is important to note that science and research are
continually moving forward, and that medical practice
must keep pace. In 2001, AHRQ reviewed the guidelines
it had developed in the 1990s to determine which were
still scientifically valid. Among those found to be out
of date was the Quality Determinants of Mammography,
a guideline that was published in 1994 and is therefore
8 years old.
Given the restructuring of AHRQ’s guideline development
activities in 1996, the evidence base for the guideline
has not been updated since its initial release. A recent
study sponsored by AHRQ has shown that the lifetime of
a guideline is variable, but, generally, guidelines should
be reviewed every 3 years
AHRQ now makes evidence-based guidelines available through
the National Guideline ClearinghouseTM (NGC),
an Internet-based compendium of more than 1,000 evidence-based
clinical practice guidelines found at www.guideline.gov.
At this time, the site contains 76 guidelines related
to breast cancer and 23 related to mammography. AHRQ sponsors
the NGC in partnership with the American Medical Association
and the American Association of Health Plans. The NGC
Web site provides the most current recommendations on
screening mammography from leading guideline developers
in the United States and around the world.
The NGC is an internationally recognized source of high-quality,
evidence-based clinical information. Currently, NGC has
approximately 55,000 user sessions and 950,000 hits a
week. Guideline developers are contacted yearly to verify
that their guidelines are considered current. After 5
years, if the developer has not reviewed its guideline,
it is withdrawn from the site.
Research on Mammography
AHRQ sponsors health services research that helps to
inform the delivery and quality of health care services.
The Agency has supported a number of important studies
on the quality of mammography, its interpretation, and
access to screening.
A study by Craig Beam, Ph.D., of the Medical
College of Virginia, found that U.S. radiologists
looking at the same mammogram are likely to interpret
it quite differently. In their study sample, Dr. Beam
and his colleagues found that some radiologists referred
100 percent of women with cancer for biopsy, while others
referred only 47 percent. Inaccuracy in mammogram interpretation
may mean that breast cancer goes undetected or is detected
at a later stage, when it is more difficult to treat successfully.
Another AHRQ study, co-funded with the National Institutes
of Health, is attempting to identify reasons for variability
in the interpretation of mammograms. The study, led by
Joann Elmore, M.D., at the University of Washington, is
a unique collaboration among three geographically distinct
breast cancer surveillance programs in the states of Washington,
New Hampshire, and Colorado. This collaboration will permit
the collection of breast cancer outcome and interpretive
data on more than 500,000 mammograms from 91 facilities
and 279 radiologists.
Dr. Elmore’s study is especially timely because it takes
place in the community setting where the majority of mammograms
occur. Although mammography facilities are subject to
rigorous accreditation standards regulated by the FDA,
requirements do not include an evaluation of
radiologists’ accuracy levels in mammography or address
the issue of variability in interpretation. Identifying
the causes of variability of interpretation will be extremely
important in enhancing the quality of screening mammography.
The Agency also is supporting research to understand
barriers to breast cancer screening and improve access.
For example, a study funded by AHRQ found that negative
attitudes about mammography might play a role in the disproportionate
number of breast cancer deaths among African American
women compared with white women. Knowledge of screening
recommendations and access to free mammograms were not
enough to get some low-income black women to keep their
mammography appointments. Most of the women who skipped
their appointments said they were embarrassed or believed
that a mammogram was unnecessary if they didn't have any
Another study funded by AHRQ found that a major reason
women cite for not undergoing breast and cervical cancer
screening is that their physicians never recommend it.
Older women, in particular, are less likely to be screened.
This may be due in part to conflicting professional recommendations
for screening older women, the many competing causes of
mortality as women age, and possible negative attitudes
about screening held by doctors and their older female
An important element of AHRQ’s research agenda is helping
to ensure that the research it sponsors is translated
into improved clinical practice. The first step in this
translation is the publication of these findings in the
professional literature. The Agency also works with professional
and patient groups to disseminate the findings to those
who can put them to work in routine medical practice.
New USPSTF Mammography Recommendation
The debate over the usefulness of mammography has recently
intensified. Much of this debate has focused on the critiques
of the scientific literature on mammography screening
by Olsen and Gotzche of the Nordic Cochrane Center in
Over the last two years, the USPSTF has been reviewing
the same scientific literature. The findings from this
review were the foundation of the mammography recommendations
released by Secretary Thompson on February 21.
Acknowledging that the scientific evidence is not perfect,
but not as flawed as others have claimed, the USPSTF recommends
screening mammography every 1 to 2 years for women age
40 and older. Evidence of benefit and reduced mortality
is strongest for women aged 50-69, the age group generally
included in screening trials.
The evidence was unclear on when women should have their
first mammogram and how frequently they should be screened,
so the Task Force recommends that women should discuss
their personal preferences and the harms and benefits
of mammography with their clinicians to determine when
to start routine screening mammography and the optimal
interval for screening.
AHRQ is working to get the new USPSTF recommendation
translated into improved clinical practice and into information
that will help reduce confusion and anxiety among patients.
As a start, AHRQ has made the new recommendation on mammography
available on our Web site at www.ahrq.gov/clinic/3rduspstf/breastcancer/index.html.
Also available are a fact sheet for clinicians and information
AHRQ also will use the Put Prevention Into Practice (PPIP)
program to help get this information out to preventive
services providers and patients around the country. PPIP,
an AHRQ program, is designed to increase the appropriate
use of clinical preventive services, such as screening
tests, immunizations, and counseling, which are based
on USPSTF recommendations.
AHRQ has a tradition of supporting and conducting evidence-based
research and translating that research into improved clinical
practice. The Agency also has led the way in providing
evidence-based information for health care decision making
for mammography, other important screening tools, and
other clinical issues.
As HHS Secretary Tommy G. Thompson said on February 21,
screening mammography can save lives. But this test is
not perfect, and we need more research to improve the
mammography and the interpretation of results. We also
must ensure that women have the information they need
to make decisions about their own health. Finally, it
is particularly important that we continue periodic evaluations
of the available scientific literature to ensure that
medical practice and patient decisionmaking are based
on an up-to-date foundation of evidence.
Thank you very much for the opportunity to comment on
this important issue, and we look forward to any questions
that you may have.
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revised: March 7, 2002