Reviewer's report
Title:Patient Understanding of the Revised USPSTF Screening Mammogram
Guidelines: Need for Development of Patient Decision Aids
Version: 2Date:13 March 2012
Reviewer: Robert Smith
Reviewer's report:
Compulsory Revisions
Page 4: The endorsements of ACP, AAFP, and (sic) World Health Organizations
should be supported with citations. Do the authors mean organizations outside
the U.S., or actually the WHO? I wasn’t aware that the WHO endorsed the
USPSTF recommendations.
Page 4: The authors may wish to be more specific about the criticism of the
USPSTF guidelines. Some of the criticism, specifically what the authors mention
here, really is not valid in the context of the Task Force’s focus, which is the
average risk population. As for the lack of ethnic specific recommendations, no
organization issues breast cancer screening recommendations by ethnicity.
Rather, more appropriate criticism focused of the USPSTF’s recommendation
changes on the underlying methodology of the systematic review and the
interpretation of the results; specifically that the USPTF underestimated benefits
and overestimated harms. Some of this criticism is detailed in reference 10, and
the following:
Berg WA. Benefits of screening mammography. JAMA 2010;303:168-9.
Hendrick RE, Helvie MA. United States Preventive Services Task Force
screening mammography recommendations: science ignored. AJR Am J
Roentgenol 2011;196:W112-6.
Javitt MC, Hendrick RE. Revealing Oz behind the curtain: USPSTF screening
mammography guidelines and the hot air balloon. AJR Am J Roentgenol
2010;194:289-90.
Hendrick RE, Helvie MA. Mammography screening: a new estimate of number
needed to screen to prevent one breast cancer death. AJR Am J Roentgenol
2012;198:723-8.
Page 6, regarding prior screening history, does the institution have a policy of
recommending annual screening? If so, this would be worth mentioning, since it
is likely that this group of women believe that their doctors had been
recommending annual screening at the time the recommendations changed.
Page 11, I think the authors have misinterpreted the survey results based on
data reported on the Annals of Internal Medicine web site. That survey was
based on a self-selected sample and does not represent a population-based
estimate. Put more directly, it is only an expression of the intent of those who
visited the web site and elected to answer the questionnaire. We really don’t
know how physicians have responded to the change in guidelines. Also, a
citation is needed if this statistic is going to be reported.
Discretionary Revisions
Page 11…Since this comment pertains to the discussion section, the authors
should consider a broader discussion about the role of decision aids in the
context of the guidelines change and the effect they observed in their study.
There is little question that decision aids are important. In the case of breast
cancer screening, in the early days women were told to get screened, with most
of the emphasis on benefits and little additional information on limitations and
potential harms. Over the years, it has become appreciated that women should
know “the facts.” But, as was very clear in the revision of the USPSTF 2002
recommendations, the interpretation of the “facts” mostly was a matter of
judgment. Do harms really outweigh benefits? There are no really comparable
metrics to answer this question, so it is a judgment call. Anecdotal evidence and
these findings suggest that most women are not making the same judgment that
was made by the USPSTF. Would a decision aid change their mind?
While some orientations to shared and informed decision making take the
approach of telling women what to expect while recommending screening, others
view shared and informed decision making as something closer to informed
consent, where the referring physician might, or might not, include a range of
guidelines as just one additional element of information in the decision making
process. It is quite clear that much of the information is complicated, esoteric,
and easily misunderstood, or at least interpreted differently. In this report, the
survey results indicated that a substantial fraction of women were confused and
anxious about the change in the recommendations. However, it is not clear that
decision aids would reduce anxiety if the source of the anxiety was a feeling of
less protection with the new recommendations compared with the old. What also
is missing here is the institutional response to these guidelines? Did the practice
change their recommendations to be consistent with the new USPSTF
guidelines? Would that have resulted in greater confidence about the change?
Consider that change to cervical cancer screening guidelines that recommend
less frequent screening and beginning screening later have largely been
consensus guidelines across organizations, yet do not seem to have resulted in
fewer women getting annual Pap smears.
Are the authors advocating decision aids to help understand the USPSTF’s new
recommendations, or to help compare and contrast the USPSTF
recommendations with those of organizations that recommend beginning
screening at age 40? The authors are encouraged to explore this issue more
broadly since otherwise the nod towards decision aids is superficial and neglects
the broader issues, i.e., the context of the findings from the survey, different
guidelines from trusted organizations, the interplay between the institution’s
screening recommendations (pre and post Task Force recommendation change),
and whether decision aids should provide information with the context of a single
recommendation, or multiple recommendations.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
No financial competing interests.
I work for an organization whose breast cancer screening guidelines differ from
the USPSTF's.