Reviewer's report
Title:Patient Understanding of the Revised USPSTF Screening Mammogram
Guidelines: Need for Development of Patient Decision Aids
Version: 2Date:12 March 2012
Reviewer: Stephen Taplin
Reviewer's report:
Major compulsory revisions:
The two major challenges that must be addressed in the paper are 1) whether
you are saying the USPSTF guidelines, the release of the guidelines, or the
media is the source of the confusion, and 2) whether the confusion means that
“decision aids” are needed. It is not clear what you mean by aids and whether
there is evidence they offer a potential solution. They may, but you haven’t built
that case except through showing women are confused. Maybe what is needed
is a media blitz, or an educational program teaching physicians how to do shared
decision making. You need to lead the reader to your conclusion logically.
In the background section page 3, second paragraph:
Regarding the statement: “The USPSTF revised etc. …”
The recommendation summary is only part of what they said as you note later in
the manuscript. The publication includes both this statement and the second
statement cited later in the manuscript. It would be more accurate to state, "The
announcement regarding the guidelines published in the Annals of Internal
Medicine emphasized that the USPSTF had recommended against routine
screening" etc.
Here is a direct cut and paste from the paper announcing the revision in 2009 in
the Annals of Internal Medicine”
“The USPSTF recommends against routine screening mammography in women
aged 40 to 49 years. The decision to start regular, biennial screening
mammography before the age of 50 years should be an individual one and take
into account patient context, including the patient's values regarding specific
benefits and harms. (Grade C recommendation)”
Regarding the statement: “These recommendations were based on modeling
etc.”
The statement isn’t completely correct. The recommendation regarding screening
for women ages 40-49 is based on the evidence regarding efficacy of screening.
The second is based on modeling.
Page 8:
Regarding: Supporting the notion that the revised USPSTF screening guidelines
have contributed to increased confusion about age and frequency of
mammography, the majority of patients (66.7%) reported being more confused
following the release of the revised guidelines (Table 2).
Attribution is an issue here.
You've established earlier in the manuscript that most women learned about the
guidelines through the media, but you state here it was the guidelines that
created the confusion. What evidence do you have it was the guidelines and not
the media that created the confusion? A much clearer statement would be
focusing upon the "release of the USPSTF guidelines" rather than the guidelines
themselves. Such a focus might also build a stronger case for the need for
information on a variety of forms that helps women and their physicians discuss
the benefits and harms of screening.
Page 9:
Regarding the statement: “The current study examined the impact of the revised
10 USPSTF guidelines on patients’ understanding and emotions (e.g., anxiety)
related to screening mammography.”
As you note earlier in the manuscript you didn't find out about the impact of the
guidelines. You state later that you surveyed women after the “release of the
guidelines”. You found out about the impact of media communication regarding
the guidelines. What you studied was women's perceptions of the guidelines.
These are not trivial distinctions, they are fundamental to communicating clearly.
It would be a stronger paper to say you studied the effect of the “release of the
new guidelines” rather than the guidelines themselves.
Page 11:
You state there is an “immense need” for “an educational tool” but do not provide
a citation or evidence that there is “an educational tool” or that such a tool
relieves anxiety and confusion. You finish by saying a tool is being tested. The
issue is partly communication, but that is what this paper is about; problems in
communication. Please clarify the basis of the first sentence in the paragraph. Is
it the only think that the confusion and anxiety suggest are needed? Should the
tool include a shared decision model or “could” the tool include such a model?
Minor essential revisions:
Page 6:
Regarding: “A secondary goal was to examine potential differences in the data.”
Do you mean differences among the women or the data.
Page 10
Regarding the statement: “It should be noted the USPSTF later updated their
recommendation against routine screening for women ages 40-49 years old in
December 2009, stating that screening should be on an individual basis with
emphasis on informed decision making by patients [5, 9, 12].”
Earlier in the review I pasted the original paper’s statement. The USPSTF did not
update their recommendation; they clarified their communication by changing
their emphasis to the second sentence.
Page 12:
Regarding the statement. “However, the study population reflects a majority of
the US population.” How do you draw that conclusion? Can you provide data that
compares the US population to your population?
Conclusion:
You might consider casting a wider net of need. It isn't clear from what you have
written, what you mean by "decision aides" and whether that is the paramount
need.
Discretionaary revisions:
Page 4 first paragraph “Critics of the revised guidelines suggested
that trying to categorize all women into one model of breast cancer screening”. It
is not clear what you mean here. Do you mean include? Guidelines don’t
categorize, but then it also isn’t clear what you mean by “model” either since you
stated earlier that the guidelines were based on a model. Please clarify your
meaning.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I was a Fellow with Ned Calonge MD when we were both at the University of
Washington in 1984-85. I am an employee of the National Cancer Institute.