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Barron H. Lerner
May 26, 2023
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The United States Preventive Services Task Force (USPSTF) 2009 decision on breast cancer screening for women in their forties produced a vehemently negative outcry. Rather than recommending mammograms for all such women, as it had in 2002, the group said that the decision should be between women and their doctors. Critics not only objected to the recommendation but charged that the Task Force had not been transparent enough with its evaluation process and had issued its controversial recommendation in an unclear manner. Subsequently, the Task Force has spent considerable time and energy trying to be more transparent and communicative.
Although these are welcome developments, they obfuscate a more fundamental explanation for why the Task Force’s “C” grade for mammography caused so much protest: the differing concepts of evidence among the Task Force and its critics. To many, the Task Force’s work has been seen as the culmination of decades of growth of evidence-based medicine (EBM), a field that appraises the quality of the available evidence to guide medical decision-making. But merely developing improved criteria for evaluating evidence does not ensure that it will be seen as “correct,” let alone popular.
Task Force members would be the first to acknowledge that what they and other developers of guidelines do necessarily includes some degree of subjectivity. But this may be a difficult concept to convey given that the Task Force is charged with reviewing all of the available evidence and then generating the “right” recommendations. Attention to Task Force decisions has only increased since 2003, when coverage of screening procedures under the Medicare Modernization Act began to take Task Force grades into account and 2010, when the same became true for funding decisions under the Affordable Care Act.1 This paper will use the 2009 mammography recommendation to revisit the fault lines that emerge when experts convene to evaluate and communicate what they perceive as the best evidence.
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