check check one to the meeting of the subcommittee is called to order and i'll first record my recognize my alf the subcommittee is meeting today to review the new breast cancer screening recommendations issued by the u s preventative services task force just a few weeks ago by now i'm sure everyone in this room is familiar with the new guidelines or at least we're familiar with the controversy surrounding them from what i've heard from my constituents friends family members and academic institutions in my district there are a lot of questions for a stray ssion and confusion around these new recommendations the controversy that was ignited by the report may be eclipsing what the report actually says and this is the reason why i'm holding this hearing today it's time for all of our questions to be answered we want to clear understanding of what the report did and didn't say and what others have to say about the report we also want to understand the process used by the task force should they operate for example with more transparency do they get sufficient input from stakeholder groups do they consider different opinions and i've invited the u s preventive services task force to speak directly about their work  my hope that we will all walk out of this room later today with a better understanding of how these recommendations came about how they should be viewed and what exactly they mean we want to get these answers who want to know as much as we can because women and their doctors deserve to know what is best i also want to hear from organizations advocacy groups and medical experts we don't want the task forces report to stand alone if there are different opinions i know that some of the frustration is due to the fact that this recommendation was seemingly made with little input from these groups that may be a problem of process as well as a problem with the substance of the report and they will have a platform and a voice today the united states is at the forefront of medical research and innovation investment in science has led to the development of early detection methods for certain cancers has led to treatments and cures for diseases once or the death sentence and it's important that all of this new medical information is used to empower physicians and their patients when making medical decisions this information should be used to help patients and their doctors it should not be used and i stress it should not be used as an excuse to deny needed care scientific studies enable patients and their physicians to make more informed decisions about what is best for them in any given situation the study should be one of many tools patients and their doctors should have access to as much information is available they should have informed conversations but the decisions about mammography for women in their forty's should remain with women and their doctors there's a lot of disagreement in the medical community about when exactly to begin using mammography screening for breast cancer studies have shown that mammograms save lives well the same time others have highlighted the risk associated with the test for example an article published in the new york times just yesterday cites a new study that indicated that the risks associated with the yearly mammograms can actually put high risk women at an even greater risk to develop breast cancer in their lifetime though at the same time the study authors caution that more research is needed to make a more conclusive recommendation and it appears to me that the takeaway message from all this is that more research is needed and there is already quite a bit of disagreement within the community as what is best as to what is best for the patient but remember our goal is to provide the best ways of preventing detecting and treating breast cancer all the studies reports and recommendations should be used with that goal in mind and i also believe that we do not want to study or any other study to be used as an excuse by insurance companies or others to deny mammograms or treatment that would help women and again the decision should be between the women and their doctors not with the insurance companies as sensually we want stakeholders today in the task force and all groups to be heard we want to able to understand whatever recommendations are made and what the implications are from these recommendations so i want to thank the witnesses that are here today and for coming on relatively short notice and at this time i would recognize our ranking member for the for the our temporary ranking member i guess the gentleman from missouri mr  blunt mr deal will be here some point during the hearing i'm glad to substitute for him in this chair for a little while today i certainly thank you for holding this hearing on the recent recommendations on breast cancer screening and they will be large agreement from the committee and concerned about those recommendations these new guidelines or these new proposed guidelines have caused a great deal of confusion for women and their families the u s preventive services task force no longer recommends routine mammograms for women between the ages of forty and forty nine yet this group accounts for about one out of six instances of breast cancer i believe it's a huge mistake to send a message to women and their families that and health care providers that an early alert system is not beneficial or may not be beneficial as a cancer survivor myself i'm very interested in hearing from members of the task force on why these recommendations were formalized how they were finalized and then communicated to the public because i know how important screening was for me on two different cancers on two different occasions as part of my annual physical as we all know health care reform has been a hot topic for this congress in a time when we're been talking about encouraging more prevention in the health care arena these recommendations run counter to almost every other discussion that we're having i'm also concerned about how these recommendations could be interpreted should the house passed health care bill become law i find it unlikely or at least questionable that the government run health benefits advisory committee would propose including services in the central benefits package that another government appointed borders recommended are not necessary mr chairman i think this is an important  hearing i congratulate you for holding that i look forward to working with you and our ranking member mr deal from georgia on the subcommittee as we work to figure out how and why these confusing recommendations were made blunt next is our chairman mr waxman the gentleman from california thank you chairman polow for holding this important hearing today we're going to talk about an issue about which people have strong views which women should be routinely screened for breast cancer and when it's a question the resonates with every person in this room we all know someone a family member or friend who has received a breast cancer diagnosis in some instances this may be a younger woman in the prime of her life indeed just a few weeks ago this subcommittee heard powerful testimony from a member of our own congressional family representative wasserman schultz about her diagnosis and treatment for breast cancer at age forty the new guidelines for breast cancer screening that were recently issued by the u s preventive services task force have placed this issue front and center again i emphasize the word again because this is not the first time recommendations about the use of mammography and breast self exams have been revisited by the task force  any number of cancer related research or advocacy groups just as we have seen with prostate cancer screening immunization sketch and even last week cervical cancer screening as well as numerous other services new information or new interpretations of old information often results in a change in what the experts tell us works at at all or works most effectively at all and this is how it's supposed to be as the science of medicine evolves so to show the recommendations on the best use of that science i believe that is what the u s preventive services task force set out to do in making a review of its two thousand and two mammography guidelines to take a fresh look at what has been learned over the past the last several years and based upon that body of work to  professional judgment on what doctors and their patients should consider when they are making decisions about breast cancer screening while that judgment may be contentious i have no doubt it was driven by science and by the interpretation of science and not by cost or insurance coverage or the ongoing health care reform debate i'm also confident that these recommendations are just that recommendations and that the task force would not expect them to be used to take the place of the considered opinion of a physician and a patient as we will hear shortly there is a deep divide about these guidelines among other experts that i believe work i believe together with the task force share the primary goal of ensuring the best possible care for women we want to learn more about those differing views today and understand better exactly what the task force has proposed and why but in the end what must prevail is a set of recommendations that is evidence based backed by side and supported by experts in the field american women and their doctors deserve and are entitled to nothing less to inform their decisions not to make them but simply to inform them i hope that will be our sole focus here today i look forward to hearing from all of focus today because this is the canary in the coal mine this is what we get when we have government intervention starting to dictate health care policy decisions and and this will not be taken outside the context of h r thirty nine sixty two which will then set up a government system and will eventually ration care and when you have government commissions setting policy instead of a doctor and a patient relationship you get this so don't be surprised if we do not focus on how this is just one small example of how health care will be delivered this country pretty soon twenty thirteen and definitely in ten or fifteen years we'll be able to point out in h r thirty nine sixty two the ratings of a and essential benefits package and the highest rating of c women would not receive access to regular mammograms until the age of fifty one estimate finds a rational care like this would result in fifty thousand preventable deaths from women under the who go undiagnosed h r thirty nine sixty two does give the secretaries ability to add benefits but only after getting approval do so from a new burea called the health benefits advisory council will the new health benefits advisory committee take into account costs when making decisions with a committee make recommendations another government board like the task force mammograms and other services aren't covered by our government where will people turn in in canada we know all those people can turn to the u s market in the u k they are allowed to do well  to purchase their own private plan thus creating a two tiered system under h r thirty nine sixty two we create the same tiered system for the rich one for the rich and one for the poor the secretary can approve additional benefits to be covered or enhanced and a premium plans to be offered in the exchange these plans will cost more money and in twenty thirteen twenty fourteen anyone receiving subsidies to help them afford insurance can only purchase a basic plan will these people receive coverage so here is proof the government will have the ability to come between you and your doctor and that we won't need a single payer to get there the government run public option will allow them the same ability think that if we wander away from science from evidence based science in our country then it will be a march to folly  sometimes we debate and we should and question the scientists and how they arrived at the conclusion that they have come to what science is something that has been honored by the american people for a very very long time we have come through a period of time where science was not honored by the congress it was political science that drove it and scientists within the government were muzzled and we paid a big price for it certainly the task force and coming out with their information i wish there were maybe a better community cations plan i think a lot of people were simply not prepared all of a sudden to be hearing what the task force came out with but now is the sober and the prudent time to examine what the task force has come out with and why and where that that may take us now on the issue of national health insurance of course our republican friends are going to try and drag this into that  but i remember too many times where they were too slow to take up the call to reform reform reform to bring services to women especially poor women in the fight against breast cancer so today is a most important hearing and we need to remain i think devoted and dedicated to solid science in our country and to pay heed to and i think that that really drives to the core of what we're here today for and god help us if we don't this is not about anybody's political science as much as members are tempted to drag that into it and i might say that insurance companies private insurance companies have long made decisions about who they want to insure and what they will cover and women and  complicated bodies have been left out of so many of those decisions and not covered by them and that's why we've engaged in a whole new debate and hopefully we'll be successful with our efforts to reform all of that so mr chairman thank you thank you for having the scientists the experts that are here today for us to query to understand better and their recommendations and that with that we will be far more confident chairman i agree with the gentle lady freeview statement that the fight against cancer knows no ideological or partisan lines and i'm certain the doctors will be testifying before stay would agree with that it is a disease cancer is a disease that all americans fear and well that is all too often very very close to home we've learned of this committee that cancer is a complex disease still has no cure but efforts geared toward prevention early detection and treatment have made significant gains we start there because as we embark upon this hearing we must remember not to integrate embrace policies that would under the successes that we've enjoyed agree we should not make this partisan but the two thousand page gorilla in the room is the bill that this house passed two weeks ago and if things were just to stay as they are now then the task force recommendations would be just that recommendations doctors be free to accept them or or reject them but what we have written is the legislative language may take some of that freedom away from doctors and may take some of that freedom away from patients as well cancer strikes roughly one third of all women in the united states and thirty thousand texas or expect to be diagnosed with breast cancer this year so we come to these new recommendations made by the united states preventative services task force and they made some pretty dramatic statements regarding breast cancer screening now the whole concept of not participating in the monthly self exams ok maybe that's a good thing but i cannot tell you as a physician practicing obstetrics and gynecology for twenty five years in north texas the number of new cancers that were brought to my attention by the patient herself who found something on exam in fact the young physician learns very early in their course not to question the patient's clinical judgment when they come in and tell you something is wrong because very likely something is wrong we're all happy when the test show that in fact there was no problem but more often than not there is going to be something there that does deserve further scrutiny now we have these task force recommendations come up two weeks ago and i went home to texas and on my desk waiting for me was a periodical called o b gyn news not necessarily a peer reviewed scientific journal articles of the day which are of interest to practicing obedience are discussed and they had a story that ironically was a day before the taskforce recommendations came out that said headline breast cancer deaths higher without routine screening and this was from the report given to the american cancer idea out in san francisco in a rather startling statistic that a doctor to be reported to this group the three hundred forty five breast cancer deaths which was nearly three fourths of the total were in women who were not regularly screened women who were regularly screenings had twenty five percent of the cancer deaths women who did not have regular screening seventy five percent of the cancer deaths i think that's trying to tell us something and i think again the two thousand page gorilla in the room is this new brave new world of health care which congress is going to dictate health things are happening and the recommendations for united states preventive task force now carry the weight of law if you will under the auspices of the secretary of health and human services or whoever the health care commissar is that that they designate so i thank you for having this hearing i think gentleman from california ms caps thank you chairman prone for holding this hearing i'm so pleased that you and we all have responded quickly to the release of the task forces recommendation because there's been a lot of confusion underscoring the value of having hearings like this in our house of representatives i've just returned as we all have from our thanksgiving break and i was with my family and in fact as an aside i received my own annual mammogram during that time i can assure you that the message is out there but i'm afraid it's not necessarily the accurate one time looking forward to hearing  greater detail today how the task force arrived at its conclusions and what the recommendations really mean in private and sense unfortunately there are people who have completely twisted what the task force is what the task force does and what its recommendations me the scare tactics i've witnessed since the release of the recommendations have been disloyal quite frankly the recommendations are based on scientific findings this is so important to underscore now we know there is not always consensus within the scientific community or within the advocacy community both groups so important to us in setting public policy but we in congress over to our constituents and the public to listen to what a reputable group of experts in evidence based medicine and prevention have to say furthermore we owe it to them to refrain from engaging in partisan rhetoric about what these recommendations mean the united states preventive services task force issues guidelines for a whole range of preventive services they do not make coverage determinations for insurance companies public or private and ultimately all decisions should be made between patients and their healthcare professionals the task forces website  firms that their purpose is to present health care providers with information about the evidence behind each recommendation allowing clinicians to make informed decisions about implementation at the end of the day this information that clinicians should use to make decisions in consultation with their patients and nothing more so i i look forward to hearing in greater detail what the task force concluded and how they arrived at these conclusions and i hope we can stop with the false accusations before i yield back mr chairman i ask  consent to enter a letter from the partnership for prevention into the record of the partnership is a group of reputable organizations the academy an american academy of family physicians nurse practitioners physicians assistants and on and on there's about ten of them and they are calling attention to our committee on the three most common mistake that have appeared in the media one being that women that the task force recommends that women aged forty to forty nine not receiving  this is nowhere in that report and that intention of the task force to reduce costs this is nowhere in their analysis and that they are not qualified these are some of the misstatements out in the public that these this task force is not qualified to georgia mr gingrey mr chairman i thank you and we have heard already some comments from the democratic side regarding the danger of ignoring science if we go down that road i don't think we're talking about newton's third law here by the way we're not talking about exact science we're talking i think about an opinion a judgment is made by the united states preventative services take our recommendations from that organization and from the the standard of care in the community and the community the greater land area of what is best practices in the american public money for that organization but very few of them ever heard of the united states preventive services task force or and what department they are embedded and how much power they have and how much authority they may have missed  n they all find out pretty darn soon and i would i would refer them to pages and both the house and the senate bill that the senate bill of course pending the house bill thirty nine sixty two and let that this is not an a or b recommendation this is a c recommendation well mr chairman if the president had followed through if the congress had followed through on the president's recommendation of having meaningful medical lab bill to reform  health care bills then maybe physicians like myself would not have to worry too much if we decide to follow the united states preventive services task force guidelines and not or a mammogram for our patients between the ages of forty and forty nine or not recommended to them that they do breast self examination and we missed a breast diagnosis of cancer and they died from that disease  or on the other hand if we decided to ignore the recommendation and we did the mammogram and i and a lump was detected are suspicious marking on the mammogram the patient had a needle biopsy it turned out to be but that but unfortunately she developed a breast abscess and then the physician gets sued for not following the recommendations and doing that is quote unnecessary so you put those in an untenable position and you put their patients at risk of death so i think we can't wait to hear from susan g komen and from the american cancer society and obviously from the preventative services task force and the others on the uncertainty the updated recommendations on screenings for breast cancer by the united states preventive task force as a listen to this hearing i hope will bring some clarity which i feel is needed on both sides and i thank you for holding it i've only read the executive s ummary but i have several questions like why now do the task force not to see the reaction that has occurred and why was a just released as an article as important as it is the night of the briefing with press and stakeholder organization as an african american woman who's had friends and family diagnosed in their twenty's thirty's and forty's many with no known risk factors some with good outcomes and others who died because of the aggressiveness of the disease and as a physician who knows the pain of caring for women who came to care very late stage but very late stage carcinomas like the twenty four black women who are going to be reported shortly diagnosed in this city by dr wayne cedric the head of the cancer center and how it in a recent eighteen month period twenty four i'm not pleased to say the least with the reports and not specifically addressing those of us who die most often from this disease mammograms are not perfect and perhaps least so in the forty to forty nine age group but as part of  dr brawley will attest our main concern ought to be in prevention our main concern ought to be the gaps in outcomes and the lack of access of many women to mammograms exams and other screening and diagnostic mode ality while this is most evident in the uninsured co pays create almost equal barriers to women with insurance and that is the federal government doing enough as an example the virgin islands scored very high on the breast and cervical cancer grant application but was never funded  an adequate funding to meet the need until every woman has access you can well imagine that we will not welcomed i will not welcome anyway these kinds of narrow recommendations what's next cold enough to call in at least screening for calling cancer it probably saved my life and not having one has caused me to lose too many friends the passport is independent which i consider a good thing it's also very important to base decisions and recommendations like these on science but the task force is not as diverse as it needs to be to adequately and appropriately appropriately address the health care needs of all americans the recommendations may have been very different or at least more expansive if some of the recommendations that the american cancer society offer that have been accepted there similar to was that we recommended for h r thirty nine sixty two but i welcome everyone all of the panelists today and i look forward to the testimony thank the gentleman gentleman from pennsylvania mr pitt thank you mr chairman for convening this hearing on november sixteenth the u s preventive services task force released its updated breast cancer screening recommendations for women in the general population several of the recommendations have shown it's caused widespread confusion and concern primarily its recommendations for women age forty to forty nine the task force recommended against routine screening mammography and women age forty to forty nine but did say that certain patients in this age range based on individual individual factors should be screen this is a change from the task force force's two thousand and two recommendation that all women aged forty and older receive screening mammography every one to two years the u s preventive services task force was first convened by the public health service in one thousand nine hundred four and since one thousand nine hundred eighty it has been sponsored by the agency for health care research and quality division of the department of health and human services it is instructive therefore to pay attention to what the secretary of health and human services had to say about the task force recommendations on november nineteenth secretary kathleen sebelius said quote my message to women is simple mammograms have always been an important lifesaving tool in the fight against breast cancer and they still are today keep doing what you have been doing for years talk to your doctor about your individual history ask questions and make a decision that is right for you and quote basically she told women to ignore the task force recommendations the good news for women aged forty to forty nine is that they can talk to their doctors and determine whether or not routine mammograms are best for them the bad news is that if house passed health reform bill h r thirty nine sixty two becomes a law a woman in that age range may not be allowed to have a mammogram the house passed reform bill renames the u s preventive services task force the task force on clinical preventive services as part of the bill's essential benefits package preventive services including those services recommended with a grade of a or b by the task on clinical preventive services must be covered but according to the task force has just released recommendations routine mammograms for women aged forty to forty nine received only a grade c should the health reform bill become a law the new task force will make recommendations to the health benefit advisory committee which will determine what is and is not covered in the essential benefits package i think we should ask ourselves how likely it is that one government board the health benefits advisory committee will recommend including services in the essential benefits package that another government board the task force has recommended not be covered it is important to note that all private plans in the exchange will have to meet the essential benefits package but they cannot exceed it a private insurer cannot add additional benefits above and beyond what the government requires and the essential benefits package except a premium plus plans and then only if the added benefit is approved by the health benefits commissioner so for example if this general benefits package did not cover routine mammograms for women age forty forty nine insurance plans would be forbidden from covering them my state of pennsylvania requires that all plans cover mammograms for women age forty to forty nine if this bill were to become law and the secretary were to adopt these breast cancer screening recommendations as is as part of essential benefits package pennsylvania would either have to change its benefit mandate law or reimburse the government for the added cost of screening this population these recommendations should be a wake up call that government run health care hearing today because it not only gives us an opportunity to further understand the recommendations as to breast cancer screening but screening but it affords us an opportunity to raise awareness about the real issue involving women tell in america and that access to care plain and simple for women in america access to care affordable health care including screenings of all kinds eclipse's the debate over what age women and their doctors should begin routine mammograms of for millions of women across america this debate has no application whatsoever they're not receiving screenings at age fifty they're not receiving screenings at age sixty they simply do not have access to affordable health care because our health care system in this country is broke it's very basic we know that if you do not have affordable health care you are less likely to receive the vital preventative screenings that women with insurance have the american cancer society reports that in my home state of florida if you don't have health insurance you're simply not going to receive any screening of whatsoever you women in this country just do not have access to affordable affordable care maybe one quarter of women in the state of florida that do not have health insurance will receive some mammograms during the age forty age forty to sixty and it is much worse if you're african american or latino the disparities in screening diagnosis treatment exist and i think this is the critical issue that donna kristen chen has raised it really does great deal of attention and debate and it is the proper place for our outrage over the women and america because regardless of your insurance if you're african american you are one point nine times more likely to be diagnosed with advanced stage of breast cancer than white women and hispanic women are almost one of the half times more likely to be diagnosed so the real concern here in the proper place for outrage is access to care in another far broken system prevents millions of women in america from even being part of this debate over screening fortunately due to the efforts of many over the past year we are on the road to correcting this problem and i hope that we can focus on the true issues of our broken health care system in america that affect cancer screening but really at the heart of the heart of the host of disciplines and math is one of them and when you look at what the task force recommendations have done it is absolutely disingenuous to say cost didn't play a role in it let me quote you from the american cancer society  the test for says that screening one thousand three hundred thirty nine women in their fifty's to save one life makes the screening worthwhile at that age yet the task force also says that screening one thousand nine hundred for women ages forty to forty nine in order to save one life is not worthwhile when you look at their executive summary clinical breast examination specifically talks about costs the principal cost of a c b e is the opportunity cost incurred by missions in the patient encounter clearly cost as a consideration they did it with digital mammography digital mammography is more expensive than filmography and talks about the cost benefit analysis of that as they work their way through magnetic reis resonance imaging magnetic resonance imaging is much more expensive than either film or digital mammography to say that cost was not a factor in this is not being honest it's just not it clearly was the reason and to say well they don't have any authority wait to that insurance company comes out and says well we based it on this task force a government task force recommendation says i don't have to pay for mammography for a woman between the ages of forty and forty nine that's where we're going to matter fact in your two thousand page bill that's exactly what you do they help benefit and the advisory committee is created to do exactly that and how do we know that because the national institute of clinical effectiveness the nice board in great britain is the very organization that limits things like pap smears they raised it from twenty three to twenty five for young women why why did they do it because science told them nope to save money and what the math part of your science equation is we think that we're willing to accept that more women will be diagnosed later on in the later stages of cancer we're willing to accept a higher mortality rate to save money that's what this report says and that's what we're getting ready to foist on the american people that is not a scare tactic that's reality and it happens in great britain and it happens in canada and it happens in france and what we are saying is we can and should do better i am a cancer survivor because of early screening i don't mr blunt is a cancer survivor because of early screening why we would  kind of an ugly system and hide behind the fact that we will have more deaths more mortality because of cancer because of it is beyond me what we're saying is this this two thousand page bill and its one  hundred eighteen new boards commissions and other government agencies that will dictate your health care policy is wrong and we can and we should by these women in their forty's do much better and i would yield back the remainder of my thank you mr rogers thank you thank you mr chairman for moving so quickly to convene a a hearing on the recommendations of the preventive services task force i appreciate it this committee has talked a lot about the need for evidence based science over the last year but it is important particularly when it comes to something as critical as breast cancer screenings that we do look carefully into the justification for these recommendations and they're ramifications for individual women many of my constituents have questions as do i and i look forward to to asking them but i do want to say right now that this is not something that to become a political football or in my view an attack on the need for health reform that guarantees access to comprehensive health care for women we all want to insure women especially women rotten with life with with life threatening diseases like breast cancer and make sure that they have access to the health care that they need with without preexisting condition exclusions generating denials that exist today but among the questions i've been asked how do we reduce the number of unnecessary screens while ensuring that we do not provide disincentives for mammograms that will save women's lives how do we empower women to ask for a screening when they suspect a problem how do we build on what we know today to ensure that we're getting the research in science around breast cancer prevention and treatment right what improvements are needed to obtain more accurate screens how do the grades provided by the task force mesh with its recommendation that doctors and their patients be allowed to make individual choices particularly when it comes to high risk women and how do we make sure that it adequate insurance coverage or high cost car sharing doesn't provide don't prevent barriers to screening and appropriate follow up care women across the country are getting are concerned about getting access to mammograms and other essential services and women's groups across the nation have endorsed comprehensive health reform for this very reason because they know that millions of women's lives depend on it i'm eager to hear from our witnesses and discuss the tax task forces recommendation and again mr chairman thank you for having th thank you mr chairman and thank you i will also thank you for holding this hearing so quickly on this important topic i believe i've mentioned to this committee before that my oldest sister is a twenty year breast cancer survivor so i have a keen interest in this topic  the breast cancer treatment guidelines released on november sixteenth by the u s preventive services task force have created a firestorm across the country giving rise to concerns about women's access to lifesaving screening some of commented that these recommendations are merely guidelines for insurance company companies and government officials trying to access to assess the relative value of memo graphy clinical breast exams and breast self exams in a written statement how health and human services secretary said the guidelines had caused a great deal of confusion and worry among women and their families across this country and stressed that they were issued by quote an outside independent panel of doctors and scientists who do not set federal policy and don't determine what services are covered by the federal government i am here to tell you today and to tell everyone in america that under this bill h r thirty nine sixty two which has already passed this congress that statement will not be true indeed under this bill the recommendation of this taskforce would become binding law and if so it would be devastating to access them across mammograms and nothing short of catastrophic for women's health in this country in their recent report mammograms for women aged forty to forty nine were given a grade of c under this bill any procedure given a grade of less than a or b cannot be covered by the public plan so the women that my colleague worried about who have no access to care today for mammograms could not legally get mammograms once this bill becomes law panel also found insufficient evidence to determine whether it's worth screening women over the age of seventy four again because the grade was neither in a nor a b it was an eye insufficient under this bill those women could not get mammograms screaming legally under any public plan but it's important to understand precisely how far this bill goes because it does not just prohibit mammogram screening if this were finding of this same task force after a thirty nine sixty two becomes law it would prohibit private insurers make it illegal for private insurers to provide mammogram coverage to women in these age groups that's what the law says let me explain under the house bill private insurers can offer for health plans one a basic plan to an enhanced plan three a premium plan and for a premium plus plan under section three zero three of h r thirty nine sixty two women purchasing insurance under the first three categories basic enhanced or premium would not be allowed to purchase because the insurance company would not be allowed to offer a policy covering mammogram services that's right it would be illegal for a private insurance company in any one of those first three categories basic enhanced or premium to offer coverage for mammograms because an over mammograms were not given either an a or a b rating with regard to the top category premium plus a plan an insurance company could offer coverage for mammograms but if and only if the health choice commissioner specifically allowed the policy to cover mammograms now i don't suspect that many of my colleagues on the other side of the aisle understand that aspect of this bill and i hope that before this bill or anything like it were to become law they would study it closely and recognize what is wrong with it certainly having the government prohibit people who choose to be able to buy a mammogram coverage not what was intended by the authors of this legislation but in fact that's what the bill does the government would bring at it millions of women mr sarbanes thank you very much mr chairman for holding this this hearing i expect we're going to hear a lot about rationing today from the other side to me the discussion today isn't about rationing it's about being rational in looking at all of the evidence that's available to us and making smart decisions about what kind of treatment we should deploy what kind of coverage there should be and i think the jury is out on this that's why we're we're having the hearing there have been recommendations that have been put forward they appear to me to be based on very extensive studies research and science and i think we ought to approach them with an open with an open mind i'm glad we're having this hearing i think this is exactly the kind of thing we should be doing and the fact of the matter is that as science advances it causes us to revisit treatment and that's a good thing now the may be other considerations at play here one of them is clearly high attention that there is to modify the screening in the education effort that is going on with women across this country  to make them more sensitive to this as a screening tool so all of those considerations ought to be fed into the mix and i would expect that the secretary of h h s will be considering all of those things going dispassionate consideration i think that's what we're called upon to do i would assume that that's what the health benefits advisory committee would do in receiving recommendations from any other government body the notion that that one got no and we've heard this theme again as well today the notion that one government body will accept without any kind of independent judgment or review the recommendations of another government body i don't think makes any sense i think that the health benefits advisory committee will look at all the factors in determining what ought to be the policy when it comes to treatment so i mean this is a good conversation to be having and i thank the the commission for putting the recommendations forward for basing them on science and now we're going to have to consider those in the light and then the many factors in judging how to how to move forward so i look forward to the to the testimony of the witnesses you thank the gentleman gentlewoman from tennessee miss blackburn thank you mr chairman and i want to say thank you so much to our witnesses for being here i am really appreciative of the opportunity for us to have this hearing today and i have a formal statement our submit for the record but i do want to make a few comments as we began this this is an issue of tremendous concern to me i think that all of us are concerned about the welfare and the health of women were concerned about what you all as the task force brought forward sure were concerned about the science and i want to discuss with you that science where you drew that from and your process i also want to explore with you your task force structure and look at the linkages that you bear and what would happen if h r thirty nine sixty two were to be passed to and read into law you all have a portfolio of one hundred and five topics that get to the heart of the issue because when you start reading on h r thirty nine sixty two on page twelve ninety six into title story and you look at section twenty three zero one of this bill the decisions you make do end up having the weight of the law place hind them and when you read specifically on pages thirteen seventeen and thirteen eighteen you see exactly what is going to happen with your recommendations and then you go in and you look at how it becomes the standard of the law so i encourage everyone to take this building on and read it and read that title look at section thirty one zero one look at section twenty three zero one go back and look on pages one t n to one twelve how what you do and how you give priority and preference to treatment in certain categories is going to carry the weight of law now it is of concern to me when i hear statements made by members of congress that we are going to deploy certain treatments our certain health care that ability should rest with the patient and their physician we do not need a bureaucrat in that exam and yes indeed when you read this bill we do have concerns that it will lead to rationing because of decisions that they are being made on call and not on health care so i welcome you all i appreciate your time we're going to have a link to the number of questions to mr chairman i yield the balance of my time thank you gentleman chairman dingell gentleman from michigan s preventive services task force they're a little bit like listening to the fairy tales of the brothers grimm but to shut the record straight i want my colleagues to understand the bill does behave as my republican colleagues would have us believe it does not use these kinds of recommendations to suppress treatment or interfere with the relationship between the patients and the doctors this is the kind of scare tactics that i've heard from that side of the aisle with always with great personal offense they talked about how we're pull the plug on grandma how we're going to push euthanasia forward how we're going to deny health care to deserving people because of this legislation these recommendations that we're going into this morning are recommendations nothing more and to say anything different than that is either to transmit the grossest kind of i and i hope this is not the case or just plain outright deceit it is time for us to look at these recommendations as they are the recommendation of a scientific panel created to make advice on what is the best medical practice and how we can see to it that way best protect our women with regard to things like  things and i'm grossly affronted by the statements that i've heard coming from the other side in which they tell us how these recommendations and the health bill of which we are working so hard are going to deny women mammograms proper memoir graphy and pap smear and other needed services that is essential if it is just plain wrong it is absolutely false and i would urge my friends on the other side who often take a look at the bill to read it carefully and if they need any assistance in understanding what the bill does i will be happy to volunteer to provide time so that they may come to have a better understanding of what the bill does and they may then make more informed statements on these matters we need to deal with our health problems in a responsible way we need to see to it that we address the honest defects which are in the bill but not to manufacture a lot of fear and faults which do not exist i am a fretted mr chairman and i hope that this record in this hearing will correct shaun of the unfortunate miss apprehensions and miss opening statement i think it goes without saying the person listed eamonn the professional respect that i have for him having said that there are no fairy two the u s preventive services task force is given the authority and i quote to determine the frequency the population to be served in the procedure or technology to be used for breast cancer screenings covered under the indian health service section three zero three the legislation states and i quote the commissioner shall specify the benefits to be made available under the exchange participate in health plans in quote in plain english chairman what this means is the new health choices commissioner will determine what preventive services including mammography are covered under the health insurance that's based on this in this bill now we also know that the u s preventive task force is an outside independent counsel the doctors and scientists who make recommended they do not set federal policy in the don't term and what services would be covered by the bill but their recommendations are going to be seriously listen to i have and who passed away in early fifty's as a consequence of breast cancer i have a sister who was diagnosed with breast cancer in her thirt luckily receive proper treatment had a msec to me and so far in the last ten years is cancer free i have a wife beautiful wife who's under the age of fifty and she has annual mammograms every year i have a good friend who was just diagnosed with breast cancer who's in her mid fort again she's undergoing treatment hopefully she's going to have a good outcome to have a task force to make the recommendation that has been made and to have in this bill the authority that's given to various on elected bureaucrats to make health care decisions including coverage and frequency in my opinion wrong is wrong now on a bipartisan basis this subcommittee in the full committee repeatedly has passed bills increasing and supporting the early detection of breast cancer prevention research i mean we do it almost every congress so we're starting down a path in my opinion of socialization of medicine in this country with the passage of this bill out of this committee with its passage on the house floor waiting approval in the senate this is an excellent time to hold this hearing i appreciate the chairman and the full ranking chairman subcommittee and full committee chairman personal attendance but let's don't talk about fairytales let's talk about the facts the plain english of these bills and if we continue to agree rhetorical then we need to begin to make substantive changes in the legislation to prevent what we all we oppose we don't want rationing of health care in america we don't want to intervene between the doctor patient relationship we don't want young men young women or for that matter more mature women over the age of seventy for developing breast cancer because they're not allowed a mammogram my good friend in my right mr rogers of michigan and a minute that was passed that committee that explicitly prevented the rationing of care and it mysteriously disappeared in the bill that got reported out of the rules committee in the dark of the night some staffer on the majority side or maybe a member i don't know decided that the will of the committee didn't mean anything it disappear maybe we need to put that back in i don't know so i have great respect for this committee i have great respect for the leadership on the committee but let's don't talk about fairy tales when we can raise these bills now i'm not saying the bills of fairytale but i will say the bill is not reflective of the policy that members on both sides of the say they support that mr chairman i yield thank you next the gentleman from texas mr green thank you mr chairman and i appreciate the opportunity you have been so quickly dealing with this first of all i want to thank the chairman emeritus for his offer for the chairman dingell willing to conduct a class on remedial health care comprehension and mounted question is it going to be mandatory or permissive and hearing my colleagues on the other side talk about unelected bureaucrats unelected insurance companies do this every day right now and i'll give you an example when i moved to be a member of congress my wife had been getting annual mammograms and yet our new insurance in congress refused that after the first year and she was a survivor her mom was a forty year survivor of breast cancer and so she fit the exception and it took me is a member of congress saying i can't practice law but believe me i will file suit against my carrier if they don't continue to pay for those mammograms you have to fight for the care that you want and to say that the house bill that passed would set up this unelected group to do it all rest on our shoulders and i think that decision ought to be made by elected officials now this group will take recommendations from every every one but ultimately it's going to be our decision will continue to provide legislation to have minimum benefits and the statement i have in two thousand and two the task force change their breast cancer screening to a grade b to recommend mammograms every one to two years for women forty to seventy that that was only seven years ago and yet now that task force is making a change two weeks ago they revise it made it a grade c the and that that's the issue i think that my colleagues are talking about that did women under at age of forty would not be automatic but should not be denied and again it does go back to the doctor and the patient's decision and i have them fact doctors on both sides and i have doctors tell me all the time that they have battles with insurance companies saying we need to do this in the insurance company won't allow it and and they're the ones that are practicing medicine and that's a battle that has to be followed every day no matter what happens if we pass a national health care bill but the use this opportunity to pick at the national health care bill i think is is interesting because the task force was will be given an opportunity to clarify their statements and i'm glad we have the testimony here today the adverse reactions of the poor wording of the task force reckon dave obviously has not gone unnoticed by our committee in the members of the committee and back that contacted and we've been contacted by number of constituents in my district including m d anderson cancer center in houston about their recommendations they were very public they're opposed to the task force recommendations i'll continue to recommended along with many many other groups and luckily the state of texas has a mandate that all private insurers must cover annual breast cancer screenings getting at the age of forty but this new screening recommendations will call some access problems for bare barriers for women the prototype is also specially sensitive because the reform bill thirty nine sixty two states that the u s preventative task force recommendations a and b are mandated benefits and the bill also includes report language say a and b recommendations for the full floor for benefits not a ceiling  floor so the task force recommendation will be considered that but the decision could be made still whether no matter what the task force is so that's what we're here today to talk about our concerns about jeopardizing access to preventative screenings for women especially since i represent a majority latino district medically underserved and i worked for years in congress to expand the coverage of mammy grahams in our community and our primary and preventative care services i like the fact that the task force an independent commission is designed to keep politics out of medical recommendations because i can be an expert for thirty seconds on anything but i do depend on the experts to be able to make chairman thank you for holding the hearing today i understand scientifically and statistically this report information is not new and i know that mammography is not perfect by any stretch of the imagination but i want to talk to this whole report from their side because to me it's sending the wrong message to women it saying you don't have to be vigilant you don't have to take care of yourself you don't have to do preventive care and the reason that concerns me is i'm a ten year breast cancer survivor i'm one of those that persevered literally to find you know my own cancer because i knew something was wrong with my body and i had you know good doctors  help me but because of that i'm here today and we all know that earlier detection longer survival i mean that's a no brainer so many women really say to me i don't want to get a mammogram it hurt you know or whatever i just don't want to do it i heard that over and over again ever since i started to get active on this issue and then a lot of women have told me i don't want to know you know i really don't want to know if i have cancer well my whole point in this is you know you better find out sooner rather than later because of what i said before so i'm very concerned that that we are saying hey you don't have to take care of yourself women look for an excuse not to do this anyway and not to do south exams and especially you know younger women today there are so many younger women in my area there in twenty's and thirty's getting breast cancer they have their own support group and that never used to happen so when we talk about what we need to do i hope that we will very seriously consider that you know that and i'm glad the panel's going to be here to explain why they did what they did  i know that some of the groups are going to continue to recommend they do the same thing and with digital mammography now things have changed so she was younger women so mr chairman i appreciate this opportunity very much in just to look forward to hearing the recommendations from the deeply personal and deeply political issue for myself and as you've heard many of our colleagues in this room the united states preventative services task force was authorized by congress to deliver recommendations regarding efficacy of clinical preventative services ideally these recommendations will be used to inform primary medical care on november sixteenth the task force delivered new recommendations regarding breast cancer screenings incorporating the most extensive scientific evidence available among their more controversial findings were the grade c recommendation for mammography in women over forty which means that because the science does not point to any significant harm or tremendous benefit that the provision of the services should be a decision between an individual and her doctor an independent rigorous examination of the science behind clinical preventative services is an essential part of delivering effective health care the task force was doing its job and as they may admit today they could have done much more around such a sensitive topic by educating and explaining their recommendations to women across the country they could have engaged community and advocacy groups to be messengers of this information rather than combatants moving forward with additional recommendations in sensitive areas i would encourage them to do just that i came away from this report and the surrounding controversy with two additional thoughts that i would like to quickly share first we clearly need better screening and diagnostic tools mammography is not a precise enough tool we need advancements in technology that can help us understand what conditions require further tests what requires treatment and how we can best help women live long and healthy lives some of these advancements in technology are being developed in my home state of wisconsin tools to help us identify types of tissue with more precision improving the efficacy of an x ray screening for breast cancer my second point is that we urgently and desperately need health care reform we must ensure that every woman and every american has access to a regular source of care if the best approach is to discuss the option of mammography or other screening with your doctor you have to have a doctor the villain here is the lack of coverage and access to care otherwise women who are shut out of the health care system whether by stigma or lack of resources or even abusive and discriminatory insurance industry practices these women have the potential of dying of breast cancer or other conditions before we even have a chance to intervene again mr chairman thank you for allowing us this venue to discuss and clarify this critical topic it has bearing not only on the health of women but the health of all americans thank you gentleman gen thank you very much mr chairman i'll submit my full statement for the record i just i just want to say that as mr sarbanes said we've got to look at science here and we've got to look at the recommendations based on science which you know sometimes i feel revolutionary in congress saying that but but that's what we need to look at all of this all of this excitement on the other side of the aisle about how how these recommendations are going to be implemented first of all as mr creede said it's it's not a ceiling is just a floor but secondly even if they were implemented most of them probably wouldn't object to the recommendation say number one the decision to initiate regular screening mammography of women aged forty to forty nine years should be an individual one accounting for patient context and values rather than a population wide recommendation for routine screening that makes sense to me number two biennial screening mammography for women aged fifty to seventy four year number three insufficient evidence to assess the additional benefits and harms are screening women over seventy seventy five years or older and then the others so really if you actually look at their recommendations they probably do make some sense from a scientific standpoint but i've got to say it is no wonder why the women of america are unbelievably confused as to what these recommendations are saying because what they are saying is most women need to talk to their care provider and they need to figure out for themselves based on their health and their family history what is appropriate for them there it's not a one size fits all testing that makes sense to me but if you look at at the twenty four hour news cycle that's not what's being said to people they're scared they're confused and when you add the misinformation that we hear from some of my friends on the other side their triply co scared because they think now when we have a health care plan that applies to everybody suddenly they're going to be told that they don't need that they can't have tests that they need and that is simply not the case  why i came down and sat through all the opening statements and i'm looking forward to the testimony because i think we really need to clear it up what is it that we are saying should be done with mammography and testing for women and what it that women need to be talking to their physicians about ultimately it's going to be the the decision of the physician and the woman what they need and they need to figure that out and then they need to feel secure that they're getting the level of testing that they need thank you mr chairman for all americans and almost all of us have had a loved one or a friend who's been affected by it it certainly is a disease that strikes fear in the heart of all of us and i want to preface my remarks by saying that i have heard some things from the other side of the aisle that have made a lot of sense and i specifically point to congress woman myricks comments and i find them very consistent with those  provided by my colleague from colorado congresswoman de gette but we've heard some things from the other side of the aisle today that i think cause a certainly cause me  considerable concern i think that it's wrong to use that fear that we all share of cancer to intimidate the people of this country into fear of comprehensive legislation that as some of our witnesses will testify today is good for people with cancer in following up with some of the remarks made by chairman dingell there are some things this bill does not do that need to be clarified these task force recommendations will not lead to rationing care that is simply not true and i think that it's tactics like these that weaken the faith of the american people not in any one particular party but in the institution of congress nothing in this legislation prohibits insurers from covering mammograms in fact the legislation gives the secretary leeway to add to the minimum benefits package as needed i think it's disingenuous to on the one hand defend the status quo which season sure the insurance industry every day making decisions about the lives of their insureds based on financial strictly financial considerations and then on the other hand condemn a system because you speculate that these kinds of recommendations will lead to the r care second what this bill does do is it provides the benefit of insurance to millions of americans who don't have it and following on with what dr christianson mentioned earlier it's not just those americans that don't have insurance that will benefit from this bill when it comes to preventative care and access to mammograms it's those who have insurance but can't afford the co payments specifically those who are indigent or middle class americans that makes a difference for them  this bill makes preventative care a basic and fundamental right for every american that means again my and my constituents sixty five thousand of them that have no access to coverage right now and tens of thousands more who can't afford co pays will now have access to things like mammograms when they wouldn't have otherwise have that these are  questions that we all should be asking what is the net benefit of this legislation to our constituents rather than jumping to irrational conclusions adding confusion to the public and politicizing an issue which should transcend politics we should be asking these rational questions again as my colleague from maryland and indicates based on reason and science with that mr chairman i thank you once again for calling this hearing in your back mammograms for women in their forty's as we've all heard and as been discussed here the task force is no longer recommending routine mammograms for women in their forty's and as someone who cares deeply about women's health i like others was surprised by this change breast cancer is to say the least a terrible disease it's the leading cause of death for women between ages twenty and fifty nine we all know people who have been touched by breast cancer people that we love and and care about and we all know people who have benefited from early detection so this is such an important hearing and i look forward to hearing the discussion of the panel and what the recommendations basically are is that a woman should talk to their doctor her doctor and make decisions accordingly for their care but many women as has been pointed out don't have doctors and many women don't have access to health care and women who should get mammograms either under the old recommendations or the new recommendations do not get the mammogram in two thousand and seven only the seventy only seventy percent of the women in the country who should have been screened for breast cancer were screened for breast cancer and part of the reason women whether they're forty or they're sixty are not screened because they do not have insurance and because they don't have insurance they don't have access to the care that they need when they need it including preventative care so let's be clear that providing access to health insurance means providing access to preventive care which means saving so what's important is that patients and doctors are able to consult and access the care that that patient needs when that patient needs it and that the patients and doctors together will decide the best course of care whether that includes a mammogram but in order to do that people have to have access to doctors women of all ages under the health care bill that has been passed by this house will have improved access to coverage that should not be lost and certainly should not discussions otherwise representations otherwise should not be used as we debate this very important issue to the rail efforts to give women access to the health care that they need in this country i don't think that that serves women well i don't think that serves our country well and frankly i find it outrageous and i yield back thank you gentleman from iowa m thank you mr chairman and thank you for holding this important hearing i also want to commend my colleague the gentlewoman from north carolina for her eloquent and thoughtful statement on a very important topic and while i disagreed with what some of my colleague from georgia said i have great respect for his real war world experience on women's health issues and appreciate the concern he brought to this hearing but i also want to talk about the comments that were made by the chairman emeritus and others on this committee if people don't believe that rationing takes place right now in our private insurance system every day in every state in every congressional district they are sorely misguided it does happen every day under the current system which is failing to meet the needs of the american people give you a good example of a friend of mine who was diagnosed with prostate cancer and conferred with his physician on treatment options and agreed that proton beam therapy was the best choice of treatment for him and he went to his private insurance company which also is the medicare administrator in my state of iowa and his treatment was denied on the basis that it was experimental well guess what under the medicare plan that that same private insurance company administered it was considered non experimental and even though he was eligible for medicare because of his age he was still covered by a private plan through his employer and was denied coverage for the same treatment he would have gotten if he had been a member of medicare that's what's wrong with our broken health care delivery system and that's why comparative affective research is effectiveness research is such a critical part of a rational discussion about health care policy making in an earlier hearing in this same subcommittee i talked about a hearing that took place and this very room years ago when a researcher advocating high dose chemotherapy with bone marrow transplant for maddest atic breast cancer patients was the only path to cure for those women even though it had not been tested by rigorous academic research then years after that we came to the realization that many women were actually harmed and died because of being suggest subjected to that treatment and that is why by the way it is so important that the plain language amendment that i put in the healthcare bill be implemented in people dealing with health care issues i think that in its p paper the u s preventive services task force highlights why that is so important they indicate on one page of their statement that the problem was a matter of communications because they did not say what the task force meant to say that the communication of the mammography screening recommendations was poor why agree with that and all you have to look is the next two census to find out why this is what two of the census say the we said is that starting at age forty should not be automatic nor should it be denied that doesn't make sense the next sentence says what we are saying is that a decision to have a mammogram for women in their forty's should be based on a discussion between a women her doctor if you don't communicate for your intended audience in language that they can comprehend easily these barriers of communication between highly technical scientific and medical information will be a problem but the debate we're having is a healthy debate about what the most effective use and treatment for breast cancer patients is and that's what we need to focus on going forward and i  dates however our mortality rate is high because women to you to are diagnosed in cancers later stages as a witness in our panel notes in his testimony the recent recommendations provided by the u s preventive services task force november sixteenth have sparked concern a disagreement among providers patients families as well sparked a public discourse as led to further confusion and exactly as we can see from the testimony before this committee there is not consensus on screening protocols but there does seem to be consensus that any screening untreated discussion is in individual one between a provider and patient so i hope today's hearing can provide concrete information on the evidence based decision making processes of the task force  i'm also interested to hear from the cancer community and medical providers on their next steps for outreach and patient education on the benefits limitations of them are prescreening thank you mr chairman i yield back my time thank you i believe that the opening statements by members of the subcommittee so on now turn to our witnesses and if our first panel would come forward i would appreciate it just mentioned as i think you know that we have five minute opening statements is from you they become part of the record and each of you may in the discretion of the committee submitted to tional statements in writing for inclusion in the record and i would now recognize first dr col chairman and distinguished members of the committee on behalf of our fellow task force members we thank you for the opportunity to discuss a taskforce that our work our recently published recommendations on breast cancer screening have drawn a remarkable amount of attention we recognize the communication of what the word make recommendations say was for and the timing of the release was unfortunate we wish to explain the process and timeline for creating these recommendations and to clarify what we intended to say to clinicians and women the health care clinician scientists on the taskforce fully understand most to personal experience the impact of breast cancer on the lives of women and their families our job though is to rigorously review views scientific evidence politics play no part in our process these costs were never considered in our considerations we voted on these recommendations long before the last presidential election the timing of the release of the findings last month was determined not by us but by the publication schedule of the medical research journals which peer reviewed our work the current task force was created by congressional mandate as an independent body with the mission of reviewing the scientific evidence for cold clinical clinical preventive services and developing evidence based recommendations for the health care community our primary audience for recommendations remains primary care clinicians the task force has sixteen volunteer termed members representing a diverse array of expertise and primary care and preventive health related disciplines including adult child preventive and behavioral medicine woman's hell nursing and research methods the h r q director appoints members from the chair as recommendations developed from a public nomination process given the scope of topics covered subspecialists we consult on or care for those identified through skinny screening by primary care clinicians may not necessarily be recruited as members but instead are consulted to review and comment on our work at critical points in the process our current portfolio includes a broad array of one hundred five clinical preventive services that are listed on our website we strive to update topics every five years which is what prompted the new breast cancer screening recommendations to address the topic designated task force work group members and scientists at an evidence based practice center collaboratively develop an analytic framework and pertinent key questions a structured systematic review of evidence for each key question is conducted and a draft evidence for word is created with work group consultation based on the evidence review and explicit methodology the workgroup draft the recommendation statement and add an in person meeting the evidence of the draft statement are presented and discussed and the task force votes on the recommendation there is a careful attention to conflicts of interest such that members with potential conflicts are excused from discussion and vote or otherwise restricted in participation representatives of twenty four partner organizations including all primary care specialties he federal agencies and other key stakeholders specified in our written testimony and on our website are invited to participate in the discussion at three key points in the process work products are sent for review and comment by the partner organizations by subspecialty expert consultants from the relevant disease area such as and on college us and by other stakeholders such a subspecialty professional organizations and advocacy groups these products include the analytic framework and key questions the draft systematic evidence review and the draft recommendation statement as voted on all comments are considered in creating the final product final recommendation statements and evidence reviews are published in peer reviewed medical journals recommendations are expressed as letter grades based on two factors only the magnitude of magnitude of net benefit or balance of benefits and harms of providing the service and the scientific certainty about whether the service works cost and cost effectiveness are not addressed in our deliberations and making a recommendation over the past several years we have discussed whether cost should ever influence a recommendation and we have repeatedly said no for and the recommendations there are sufficient net health benefits such that primary care clinicians are recommended to provide the services for all appropriate patien if there is no net benefit or there is net harm we assign a directive dacian indicating to not provide the service if gaps in the evidence prevent net benefit from being determined we assign i statement reflecting insufficient evidence indicating that more research is needed finally ac recommendation is assigned when there is a small net benefit for c recommendations we recommend the patient be informed about the potential benefits and harms and then be supported in making his or her own informed choice about route about being tested this specific c language that we recommend against routine provision was intended for consideration by primary care clinicians but unfortunately has played out unintended ways in the public interpretation of the breast cancer recommendation congress to public law section nine fifteen mandates that h r q convene the task force to address our mission the role of h r q in the process is to support our activities and processes but our key staff and the director of h r q do not vote or otherwise influence our decisions i will have to admit to the committee that breast cancers of particular concern to me i lost both my mother in law to breast cancer and my sister is currently undergoing therapy i fully understand this issue and have to rely on the science as we provide our recommendations with that i would like to turn testimony over to  to testify specifically about the breast cancer screening recommendations i'm sorry i just want to thank dr  mammography screening i served as vice the national cancer policy board and i have expertise in evidence of systematic review and met analysis i participated in this process from the very beginning i would not sign off on any recommendation that i did not believe reflected the best possible use of evidence for the benefit of women i appreciate the opportunity to clarify for members of this subcommittee the task force recommendations and the evidence and wing of the evidence that led to these recommendations in specific the task force recommends the following women should have mammogram every other year the decision to start mammography before the age of fifty should be an individual patient context into account including the patient's values regarding specific benefits and harms that is the task force is saying that screening starting at forty should not be automatic nor should it be denied many doctors and many women perhaps even most women will decide to have mammography screening starting at age forty the task force supports those decisions the task force acknowledges that the language to describe recommendation about breast cancer screening for women forty to forty nine did not say what the task force meant to say the task force communication was everyone to two years with regard to screening younger women the task force stated it may be prudent to begin screening at an early age for women at high risk of breast cancer in its one thousand nine hundred six guide the task force recommendation was in favor of screening women fifty to fifty nine every one to two years mammogram screening for women forty to forty nine was given a c grade at that time recommendation insufficient evidence in two thousand and two the task force recommended screening for women forty to sixty nine everyone  dating at the benefits were smaller and took longer to emerge for women who were first screened in the forty's on nov sixteenth this committee knows the task force issued its updated recommendations on breast cancer services  services to clarify that the timing of the issuance of these recommendations in late two thousand and six discussion of a plan for updating the recommendation began the breast cancer topic came up for review at the regularly scheduled time work on the topic started in two thousand and seven when the top recommendation statements came up for a vote in november two thousand and seven the members could not come to agreement about what to recommend because agreement about what to say about the balance of benefits and harm identified in a systematic review of evidence for six key questions the results of an analysis from the breast cancer screening consortiums and the results of a study commissioned by the task force conducted by the cancer intervention surveillance modeling network the systematic review identified almost three thousand studies and five thousand and five hundred fifty of these were used to make the recommendation the final recommendations were made based on a weighing of the benefits and harms of screening mammography the task force concluded from the evidence that screening mammography for women forty to sixty four has a benefit in reducing deaths due to breast cancer the benefit is larger in older women than in younger women and i'd like to speak specifically to the issue of of a false positive in particular the psychological distress has been ridiculed to understand the consequences of false positives it is necessary to consider how women enter the screening cycle what happens and what might happen to a woman who has a positive test no matter the concept of screening a positive mammogram screening test means cancer until cancer is proven not to exist for some women who have a positive the time between a positive test and a statement there is no cancer is mercifully short for other women the follow up involves more than one additional test perhaps a clinical breast examination along with a trip to a surgeon over a period of time that is not always short and over a period of time is unpredictable and not within the control of the woman some women eventually need to biopsy cancers terrifying prostitute it carries special emotional weight because of the consequences of the diagnosis in the past but the prospect of mutilating surgery anxiety and psychological distress in women who have had positive screening tests is in the evidence the task force wants only that screening mammograms be done with full knowledge of these potential harms the frequency harms and what is to be gained by being screened and earlier compared with a later age false positive tests are more frequent and younger than in older women other false other harms of memory graffiti include ones that are less well documented some women are diagnosed in their forty's with cancer that could have been treated just as well if diagnosed later these women may have unnecessarily be an exposed to the harms of treatment including surgery chemotherapy a factor i didn't want to i don't want to stop because i find so important but you're two minutes over go in but i'm only going to say  that the my final statement men moderate the starting at forty should not be automatic the task force recommends that women in their forty's decide on an age to begin street screening that is based on a conversation with their doctor and his individual and i apologize for going off i'm going to apologize for trying to stop it because it's so important that you clarify a lot of these things and i and i appreciate that our procedure now is that we have questions from the members of the of the panel i mean from the members of congress and i'll start with myself let me say that you've actually clarified some of the questions i was go very well but i still want to kind of review this if i could in my own mind and if i say anything you disagree with tell me but i do want to issue some questions as well but i look at there's a lot of myths out there that have been spread both today and certainly in the last few weeks since you came out with your recommendation and the way i understand it the current task force uses these a b c ratings these are the same kind of ratings that would be used under the the to the different task force that's in the legislation the larger health care reform legislation that we've passed in other words you are the u s preventative services task force the new task force and the bill that we passed has a different name clinical preventive services but the a b in the c ratings are are they are the same or similar but right now these a b and c ratings have no force they're just recommendations and what some of my colleagues have said is that these insurance companies now don't have to cover a b or c and i have to cover anything and in fact what we're getting is that a lot of insurance companies right now don't cover don't prefer to cover any screenings because if you do a screening and they have to pay for treatment it costs them money which they try to avoid and so what i see right now is that in some cases states have required certain screening like my own state but on the other hand we heard the gentleman from utah talk about utah where my understanding is they don't require any screening so the point i'm trying to make is that the big advantage of the health care reform bill that we passed is that h r three nine six two will for the first time create minimum standards for require prevented a benefit so private insurers would be required under that bill to cover services with a grade a or b recommendation right now they don't have to cover anything what we're doing in the bill is basically saying that at a minimum if you or your successor task force says that this is an a or b it has to be required which it's not now the other thing that we do in the bill is that we  say this is secretary could require a c rating also be covered under both a public option or private insurance plans in fact my understanding is that that the new task force i mean the secretary under the bill could even require a c rating under the basic benefit package now that's contrary to what some my colleagues and saying on the on the other side of the aisle and my whole point here is to say that the truth is that it into law h r three nine six two would result in a lot of people who are not getting my mammograms pap smears colon os copies a lot of people don't get that at all now because insurance companies basically don't have to do it unless the state requires it now under this bill they would have to do anything that you rate as an a or b and the secretary could even require the see either in the public option or in the private plan a visit under the basic benefit package now i mention this because the bottom line is that women's ability to continue to obtain mammograms increases in these house and senate bills that are being passed and then removed and when i look at the republican bill on the other side it sets no floor whatsoever there would be no minimum required benefits for insurance to provide on the republican bill essentially would be just like the status quo that we have now so i don't know you know i listen to the debate that we've had today and the bottom line is that the bill that we passed in this house provides a lot more coverage has a lot more guarantees the status quo doesn't provide any guarantees at the federal level nor with the republican alternative  that we've been given on the other side now my question is again you mention that when you recommend a c it says that it has a small net benefit and women are supposed to make their own decisions so you made it quite clear today that even if it's a c there is some net benefit and the secretary decide under the new bill to say ok that's going to be required as well so you're not in any way with this e recommendation saying that this screening is not a good thing in fact you're actually saying there is a net benefit but you would like individual women to make that decision with their doctor because it's only a small  map that c recommendation to advice that women make the decision with their doctors about whether or not to undergo skiing i think i think this committee is dealing with incredibly complicated issues about health reform in coverage but the task force is not a coverage and health care reform and policy committee were scientists but the bottom line is an out and with this is that even when you recommended see you're saying there's a small net benefit so again let's let's not talk about today but let's talk about if the bill that we passed in the house in this committee becomes law even then you know the secretary could say ok there's a small net benefit and so we do want to require this as a basic benefit or you know you basically leave it up to the insurance companies decide the way they do today but you know that the misinformation out there i think is that even under the bill that we  passed for what for once there is going to be a requirement that some of these screenings occur if you raise it is that a it has to be done if it rated as a b it has to be done if you are a to see the secretary can say it has to be done right now there is nothing nothing at all and the republicans and their alternative would continue the status quo that say you don't have to cover anything and i just appreciate as i think you've helped to help me clarify yield now to the gentleman from illinois mr shand thank you mr because what we need in this country is a continued debate on the failed health care bill that we passed on the floor of the house that's what we really need to do and that's what we're doing today and we're using obviously what happened through your process to to make the claim the short term concern of a public option which many of my colleagues on the other side has said is a gateway to a one payer system so when the government controls all the health care decisions in this country they will eventually default to control costs through ration care now the process the scientific process that you've just admitted to said there's a small net benefit when there is increase decrease revenue available the default will be based upon thirty nine sixty two just what you say on your web site your website recommends against routine screening mammography and women age forty to forty nine do you think that this statement would be perceived by unger women younger than fifty that they should not get a mammogram on your web site we have communicated very poorly about the c recommendation is clear that many women many physicians and certainly the media interpreted that language as if we were recommending against women in their forty's ever having a mammogram that was not our intention i understand  we're concerned of conditions we're concerned a bureaucracy we're concerned of ration care we're concerned bob bureaucrats saying there's no real net benefit and then we  right exactly what we're concerned about and that's why we're having this debate in the bill chairman polonca i think pretty adequately talked about the differences we know that services with a rating  and b must be included in an essential benefit package in this case with the highest rating a c women would not receive currently if this was law as it is today women in this category would not receive this as a cover benefit under this under thirty nine sixty two and that is part of our concern and this does say way into the full health care debate the commissioner on part of  don't have the whole two thousand pages i just pulled up excerpts the commissioner shall specify the benefits to be made available under exchange participating health benefits plans during each year and then you go further on basic enhanced and premium and then the premium plus approved by the commissioner and then you go to the c section which is again highlighted and we continue to have preventative services including those services recommended with a grade a or b by the task force on clinical preventative services so the the the this is again for a lot of us  important do any of you know an individual who's been diagnosed for cancer between the ages of forty and forty nine personally i know many individuals who have been diagnosed with any doctor long from forty to forty nine and then the other question what about over the each of seventy four anyone who's been diagnosed with yes because all the other we're focusing on forty to forty nine in your report said over seventy four has the eye category and we don't even know if it is so what are we saying to those over the age of seventy four i speak to the to the evidence and the mapping of the evidence to the task force recommendations and i appreciate that and i only got thirty seconds and i'm i'm going to be punctual my time part of this concern with r thirty nine sixty two is as we said the public option the gateway to one payer system eventually rationed care and then a decision made based upon the financial ability of the country to find care across the spectrum but also our seniors in our country and again this incomplete aspect for seventy four b speaks to the concern that if you're elderly in this country and we get to a one that the republicans are complaining about is not law yet your agency preventive task force is in operation this is set up under is set up under law yes ok and your job isn't to make recommendations to insurance companies is that it's correct your job is to make recommendations on preventive services so that the latest science and information about the science is communicated to clinical practitioners is not your that is correct and this is very useful information now we are focused on the breast cancer issue but that's not the only area where you've made recommendations and that that is correct how many other areas have the task force made recommendations the last couple of years let's say well our current per for leo is one hundred five total and we take up around fifteen new or updated topics annually we've recommended that teenagers be screened for mental illness yes that was the new recommendation this year congressman that we just came out with this so this is new services that had not been recommended prior and there was a breastfeeding behavioral intervention recommendation that is correct and you've had a recommendation that aspirin for the vention of cardiovascular disease the a way to prevent the disease right so you've had a whole range you say how many one hundred three hundred five total one hundred five total i'm assuming then of the others have been as controversial as this particular one is that is correct ok so we we have a controversial issue because it it it challenges the accepted notion about the frequency of breast cancer screening and we're going to hear a lot more about that from the next panel but i want to have a smoke at the challenges being raised by some the republicans which i think is all political they're acting as if your recommendations based on breaking the scientists who have the expertise which are directed at clinical people will be used to ration care that's their that's their argument we're going to ration care and they then say well that's because there's going to be a health care bill that will provide a requirement for minimum benefits now th minimum benefits in that yes you have access to hospitals you should have access to doctors you should have access to pharmaceuticals your area is in the preventive area and nothing could be more important to me then having the latest science on how to prevent diseases because if we can prevent illnesses we won't pay to treat them later your task force will continue an operation you will convene the scientist experts in different areas of prevention now how i guess the question i'm raising this to you but the question is how will your recommendations affect the minimum benefits that will be required for health care insurers health care insurers could be a public insurance if that survives in this legislative process it certainly would be private insurance right now private insurance doesn't have to abide by your recommendations is that true that is correct and some of them cover these preventive services and some of them down does naturally that's correct because it's their decision but if we're going to provide subsidies for people to get insurance and we're going to try to get a market where insurance companies compete against each other based on price and quality we ought to make sure that all of them provide at least a minimum set of benefits one of the star issues for republicans is to have a lot of insurance plans done provide any minimum benefit at all as they can they can be cheaper if they don't provide minimum benefits well i find that troubling but let's say we're going to have minimum benefits and you make a recommendation is your recommendation under the proposed bill automatically going to be in effect for all insurance do you know whether that to be the case congressman or i'm that you're not an expert on the bill the let me correct let me explain what the new bill will do the new bill will take your your recommendations they'll go to the secretary the secretary will review them the secretary will have a notice of rule and commented that public process and then decide whether that's a minimum benefit now a minimum benefit is a minimum benefit is not a maximum benefit so if there's a recommendation as you propose for breast cancer screening that will be not a requirement of insurance to do no more than that it would be a recommendation that will be required that will require insurance companies to do that as a floor not a ceiling i just want to set this out because i think some people watching this hearing may get confused when they hear stories about bureaucrats or  rationing care or the health care b bill being a gateway to single payer we expect a bill with competition and people to make choices between insurance plans but we don't want the choices be between insurance plans to be those who cover breast cancer screening and those who don't but those well at least a minimum of preventive services that we could hope will prevent diseases and the need for paying for care for those diseases tha clinical guidelines and i guess this is a reprint from the annals of internal medicine the last page of which is an appendix which lists the members of the u s preventative task services  force and that is usual we usually have at least we usually have to say which which which are those two that are on the list that i have in front of me kimberly gregory and wand nicholson and they and they both participated in this in this decision kimberly gregory was on the task force when this decision was voted one to was not there was another o b g y n on task force when this topic was in the record and we could make that information available to the committee if that's important i would like to see it out of the committee will deem it is important but i would appreciate the opportunity to see it now is there a radiologist in this group no no there's no radiologist group is that a problem the expertise of this panel has been called into question the experts are individuals who have experience in screening science and prevention radiologists were consulted and review the documents and the recommendations and provided input let's wait till it finishes bothers me to on this task force then the majority of these individuals were primary care doctors was there a general surgeon on the board or on the task force well the again the experts are experts in primary care and prevention and yes there melted they were consulted what does and i apologize for being in and out but we're doing about nine simultaneous hearings today in the financial services make over require psychological cost if you will to the to the patient in that exchange is that it would stand there correctly the issue was a qualitative assessment anxiety psychological distress inconvenience or all considered to be to tell harms of potential harms and again it's part of the net benefit equation when when i was in schools back in the hundred seventy s i realize a long time ago but mammographic screening was not at least in the area where i went to school that was not something that was done you sent someone for a mammogram is kind of a big deal because you felt something your but it wasn't done is as just part of routine screening in fact i don't think as i recall looking back was probably the mid eighty's when that became a standardized screening test and in fact in texas we don't know whether this is true nationwide but in texas i know women can sell for fur for my ma graffiti when that all happened though that psychological cost was one of the arguments that was used by people who felt that routine screening would not be a good idea so how is it that we've come to the point where we rejected it back in the one nine hundred eighty s but now in two thousand and nine this is a factor again that's that's worthy of our consideration again that this is not determinative information that we want women to know about we want to know them to know how common it is again the false positive rate is much lower as women get older and that's part of the risk benefit equation we would not want women to be afraid of having in the log or this is again one piece of information that women in their physicians should discuss when deciding when to start screening on and is that same rationale applied to self examination the task force recommended against clinicians teaching women breast self examination they did not recommend that women not pay attention to their body that they ignore lumps or that they ignore problems that might come up when they find a lot again the task force recommendation was against doctors teaching women breast self examination how are women supposed to get that knowledge  can't just get it by intuition someone somewhere along the line has got to provide them some some guidelines on the proper time to to do the examined him and how to do it and what to be concerned about  and what not to be concerned about that as i recall i don't know i may be wrong on this but i don't ever recall coding and being compensated for teaching clinic teaching breast self exams so it's not a i mean i wasn't a cost center for you i was a cost driver my only inference from that could be that you're worried that people will find things that then lead to procedures and we're better off if we don't ask don't tell  the evidence there been two very well conducted randomized clinical trials in which women were taught how to do breast self examination and both of those trials found no overall benefit in terms of reducing about to vote i think we have time for our set of questions and then we're going to vote we have five votes we'll take one more set of questions and then will adjourn and come back after the five  terminate all health benefits for the unfortunate poor and especially with regard to so i very much comfort i want to welcome you to the committee this morning i just have really one question what i think is important thank you congressman i think this is a key question the task force believes it's a major charge from congress and responsibility to primary care clinicians and patients is that we set that evidence based take in the ground immune from how much it cost to achieve the benefits associated with a given effective preventive service so short answer is  you are recommending the needed services the need to test the needed treatment as opposed to looking at the cost decide it that is correct ok now to my colleagues on the other side and i do this great affection and respect and charity you addressed this question on in your statement and you say here and i read this for the benefit of my colleagues on the other side you say task force recommendations are based on consideration the health benefits and health harms of providing the preventive services and on the scientific certainty of whether the preventive service works cost and of cost effectiveness of specific prevention services are not addressed by the task force the liberation then you say this the task force only and that's underlined consider scientific evidence of health benefits and health harm the task force has specifically discussed whether cost should influence a recommendation and has repeatedly voted to leave costs deliberations on whether or not to provide a preventive services are right that is correct now when your recommendations are made are they to put a ceiling on benefits or to describe minimum level of benefits that people should get congressman i must admit that it's outside the scope of our recommendations how they are used by other entities  now your recommendations are not expected to be substituted for the needs of the patient or the cause is sure an expertise of the doctor and they're not intended to intrude into the doctor patient relationship or my corrector not interpret wrong that is correct in fact if you read our statement as published in the annals it says the task force recognizes that the clinical or policy decisions involved more considerations in this body of evidence alone clinicians should understand the evidence and individualized decision making to the specific patient situation this actually precedes all recommendations it is a recommendation statement that we expect clinicians to do what they are trained to do in order to address the needs of the individual patient or his or her best interest say what's going on and they also are permitted to make comments to you on the task force is that not so we actually invite comments from our partners to help us do our job better to take into consideration different viewpoints and  different issues and your losses and then the task force is currently moving towards increased private citizen input with the resources we have available to consider and identify those we have prior to this time done more with input through specific groups that we invite to comment because we think they're important stakeholders this is an issue that the taskforce believes that in the interest of enhanced transfer transparency and responsibility to the american public and the patients whose physicians may consider our recommendations needs clearly states that united states preventative services task force recommends against routines grading my ma graphy and women aged forty to forty nine years do you think that this statement could be perceived by women younger than the that they should not get a mammogram we need to immediately figure out how to get that statement off the web site i think it could be misconstrued it has been misconstrued and we need to fix our website dot thank you for that response and i hope that you will do that i think it's very important i agree with you i want to ask you to cologne are you aware that the senate version of health care reform specifically section four thousand and four i think is on page eleven fifty it requires the secretary of h h s to create a national prevention awareness campaign based on all of your task force recommendations both those that you favor the a's and b s and that those you recommend against the cs and d s do you think that this national awareness campaign could be could be perceived by women young and fifty that they should not get a mammogram or perform a breast self i wonder if you congressman it would be ok if you receive your question because the first part of it and the second part i didn't well it what i'm saying is in the senate bill if it becomes law if that prevails the senate language in the conference report it becomes law and it specifically says that i named the page and section that the secretary would require the creation of a national prevention awareness campaign television ads t v spots based on all of the task force recommendations both those that you are in favor of and those you recommend against don't you think or do you think this national awareness campaign could be perceived by women younger than fifty that they should not get a mammogram  breast examination thank you for the clarification congressman so i can't speak specifically to the bill or to the policy i will speak to the indication of the recommendation which we believe needs to focus on the decision to start regular biennial screening before the age of fifty should be an individual one and take patient context into account putting the patient's values regarding specific benefits and harms and so that message which i realize is preceded by the recommends against statement is one we feel communication needs to be improved and a clear message of what the task force intended needs to lead not follow but i thank you bear with me just for maybe fifteen seconds i had one other point i wanted to make the united states preventive services task force concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography and women forty years or older that is saying that you don't recommend that the clinician a position of primary care physician o b g y n specialist should routinely do a breast examination as part of a complete physical in his or her patients that that has no value for being here for your excellent testimony and for being among the few on capitol hill who apologized but patiently and it's not a habit that we do very well so the fact that to you i wouldn't call it an apology as much acknowledging the the communication glitches that occurred perhaps and for me i think it was a lot of it being timing but i don't take it as a negative thing i think we are seeing as a very positive overall experience happening in our country not to minimize the confusion that many women experience but i think we can use that as a teachable moment to put it that way the timing of the release of the report and the debate on health care reform has been seized by many who want to detract really from the health care legislation to use your testimony  widely misconstrued ways and i want to take a minute of my time to mention one very important distinction but it's also an important point of what they health care reform bill is which actually will be augmenting a lot of the preventive work that you're doing because women will be able to have an occasion to understand more about cancer prevention in its wider forms and their behaviors and their body changes which are all essential but the essential benefits package in the exchange consists of let eleven benefit categories including inpatient hospital services as examples outpatient services maternity care prescription drugs as well as preventive but with regard to preventive services the bill says that the reacclimated items and services with a grade of a or b from u s preventive services task force shall be covered as part of the central benefits package a rightful designation of the importance of your studies and your recommendations but not a conclusive piece of it and that they say that this be something which we highly recommend that there be no cost sharing for this grade a and b of the your recommendation the benefits advisory committee part of the health reform will be able to recommend through its public standards setting process that additional preventive services such as mammograms for women under forty or between forty and forty nine be covered without cost sharing i mean there's an additional recommendation that can come as part of the health care bill the secretary may also approve such coverage the essential thing here is that the benefits package essential benefits package is a floor not a ceiling and that really is important for i want the record to state that very clearly and employer once the exchange goes into effect and there's real competition between private insurance plans they they may wish to offer more of a path attractive packages to to win more coverage is so that it would be well be understood more fully as we go along this i just wanted to make sure that that be in the record but i wanted to give you even more opportunity both of you are one of you to talk about what could the future could hold you see i think this is an opportunity while a wow moment as one of the  advocate groups put it and i want to commend all of the breast cancer advocacy groups who have brought us to a level in this country where when a recommendation set of recommendations like yours comes out that there a more intelligent audience receiving it able to understand it and able to use it and to advocate even more in a wide range of ways which i think is very healthy for our country to be a part of i want you to i'm only giving about a minute but i i'd like you to elaborate further on ways that your advice your task force can communicate in the future in ways that maybe we can access and use more efficiently what i thought would happen with these recommendations is that it would move the discussion more towards the notion of individualized decision making and risk what i thought is it might initiate a dialogue where we decided to work harder at finding out who really is at higher risk so we could make more tailored recommendations for screening and among those groups that we really have ignored are african american women who are out and women our background some of whom have a very high risk based strictly on their membership in this group again what i thought would happen would be a move towards individualized tailored risk ratify decision making and not this sort of  making i think we hear a lot about personalized medicine and i think the basis of medicine can be and should be individual decision making and it's really what we were hoping the language for the younger age group which started generating this issue about you know we as consumers of health care should understand that every test we have in every treatment we have has inherent risks and benefits and we should make our decisions based on understanding those and then what's important and that underscores the value of the work that you do in this topic and in every other topic and the importance of having educated health in areas of health a population that can the material as well as primary care providers and other doctors as well you know use your information every single day to make th kind of informed decisions that they and their patients it needs need to have before them so i hope this can be the beginning i again want to thank our chairman this is the kind of setting this hearing setting that is so important for us to take advantage and your expertise and your research and have this kind of debate if you will but discussion so i thank you again for your being here thank you mr rogers  thank you for being here and i have some quick yes or no questions if i may just to get through it were you familiar with the references to your task force in the bill as it was introduced in july so  name but in the bill and i'll just read from the bill the preventative services task force convened under section one fifteen a of the public health service act and the task force on community preventive services and then in quotation marks as such section a task forces were in existence the day before the day of the enactment this act shall be transferred to the task force and clinical preventive services and the task force on community preventive services respect the way the stablish under these sections and then it goes on to say that whatever your recommendations were prior to that enactment are in effect are you aware of that sir or ma'am well generally yes or no i'm sorry yes i've now aware of it the law of which this committee wants to enact you have now taken ages forty to forty nine and made them a category c which means they will not be paid for under this committee that's interesting let me ask you this you say you didn't consider cost every appendix that is attached to your your taskforce recommendation is that something that would been reviewed by the individuals who made a determination is that something of value that's why you attached it as an appendix i imagine yes all the material in evidence is thank you very much are you familiar with appendix c one where the question is what is the cost effectiveness of screening that assigns a dollar value by quality of years of life are you familiar with this this clearly is  cost effectiveness port portion of your study clearly you cannot in good conscious tell this committee you didn't consider cost you just told me that every piece of information according to your study is considered this is a dollar value per polity of life and it's done on  screaming i would when you remove this from your task force to study as well as your recommendation that said i'm sorry but i'm trying to see what you're pointing at and i appended to see one of your own taskforce recommendation that clearly clearly considers cost just by your own testimony and again you can see why women of america and those of us who are very concerned about bureaucracies interacting between health care on your website again you say that you recommend against routine screening you say that you're going to take that off that's great we didn't consider cost but on your own report it says you considered cost you can see why after creating a hundred and eighteen new brand new commissions just like yours all of your authority will now be in active into law according to their own bill by the reference i've just read this pretty serious and let me ask you another question as a part of this it says and i'm going to read this again from the bill because i think some of my members on the other side maybe either haven't read the bill or maybe misunderstand their own language but even under the this is the indian healthcare section section two zero six that encourage you to read under many memo graphy and other cancer screening  secretary shall ensure that screening provided for under this paragraph complies meaning you gotta do it with the recommendations of the task force with respect to a frequency be the population to be served and see the procedure or technology to be used all of which is referenced in your report imagine that when this passes your report now becomes a matter of law according to their own language in this bill right here  that would that change your consideration as a scientist knowing as by your own testimony it did not pass unanimously you say science and evidence but clearly people of equally as learned as both of you believe that that was the wrong answer and is this something you should reconsider mr rogers the no no i would like an answer no i know but i'm going to ask you to go beyond that i mean you use your five minutes you can take what time is necessary to respond because i'm not sure you even know what the questions are but you know i got my question no there were a number of different questions and i'm not sure which one to respond to what i would like to say and i want to say it again on the record that when we voted the recommendations from screening a b n c we voted them without regard to koester cost effectiveness analysis i can say that the word honestly absolutely the word cost was not in the room it was not mentioned it was heard and it did not in any way deter but it was part of your study was it not was it not part of your study you just told me that everything that was in your study was considered appendix c one considered cost  time is up and you can respond in a what you want hey we got a million dollars to chairman if you'd like i have nothing more to say mr rogers i'm just trying to make sure she has as able to respond but i think we should move on because we're a minute over now i think she's she doesn't want to say that the bill she didn't even know what was in the bill and their deliberations were done under the previous administration before president obama was even present a united states but mr chairman the point here is that she did say that the cost wasn't its part of their voting but it said even preceded the current administration but whatever let's move on next on the democratic the gentlewoman from the virgin islands this christians your mike not working there so now right thank you thank you for your presentations and your answers this far but i want to go back to the issue of african american women some years ago many of us worked to ensure that mammograms would be recommended and covered for women of african descent under age forty and given that even though we may have a lower breast cancer incidence were more than likely to be diagnosed at later stages and have a higher mortality rate and even in younger women we find that younger african american women are more likely to be diagnosed with breast cancer so in the recommendations why wouldn't the task force single out this particular group and maybe give them a different recommendation other rather than lumping all women between forty and forty nine or younger under se you make an excellent point and i think again when i expected to happen with these recommendations is that we would begin to focus on how to make more stratified nuanced recommendations that would identify those groups who are recognized as being at higher risk of consequences of breast cancer when so even though the bill says in the indian health service that  your recommendations would be applied you might look at the native american population as a group and decide that maybe a different grade for different age groups in that particular age group and make that recommendation that that might not happen that i think that the accompanying tauriel to our recommendations point is the direction that we thought we would be going out of you know not in congress trying  to defend them but moving to the point where we have more individualized risk and i would i would say that based on my understanding of the science which i follow very closely that breast cancer in young african american women is a topic which is not widely appreciated as being one which perhaps needs a different kind of recommendation but again we need to do better at risk stratification individualized immediately be able to go back and i understand but you recognize it and this is not the final answer this is definitely not the final answer i think people would have wished that we would have not even ever open this topic again after two thousand and two specially in that right now that was an accident but given what occurred in response to the article and the press taking it up and how it has been interpreted would you have you looked at other ways of presenting recommendations that might be controversial i've never really liked the fact that the press really gets these advance notices and they start to tell us what is coming up in the next medical journal because they don't really understand it well we communicated very poorly we should have spent more time talking with our stakeholder groups we should have had a formal communication plan physician agree can you explain how the over diagnosis is a bit confusing but can you explain how over diagnosis occurs when the c i s early stage lesions especially in younger and younger this is a topic which i would want to have addressed by an a medical oncologist and those who are now working so hard to try to understand better how we separate and differentiate those tumors that are going to progress rapidly in those tumors that are going to progress but this is this is outside my area of expertise was speaking to medical oncology surgical oncologist actually yesterday they feel that  precursor to invasive cancer and i'm surprised that it's listed as one of those things that maybe we're over diagnosing over treating but i think my time is up so thank you for your answers the gentleman from arizona mister chairman first i have to express some sympathy for you you stepped into a controversy which has been made much larger as a result of the overall health care reform that's going forward and i think that to a certain degree you've been sucked into a much larger battle than your own efforts to try to make recommendations would have otherwise merited as i understand your recommendation you base it on science and you say look here's what we have concluded based on that science it shouldn't be automatic it ought to be something you think through and here's our recommendations that makes a lot of sense to me tune from that that you believe that it should be a decision between the patient and her doctor and that for example if a particular patient had a history of cancer or breast cancer then you might get screening at a younger age or in some categories where you didn't feel it should be automatic but under those circumstances it should occur is that correct yes that is correct ok you would then agree with me that if the government were to prohibit an insurance plan from providing coverage for someone who after consulting with her doctor look at her family history but she needed it that would make that at least not an insurable event correct i am not here to get involved in the coverage and care reform coverage issue fair enough i will just then state for the record that in my view the government should never prohibit someone and the government should never be able to prohibit someone from offering mammogram coverage or as an insurance  company or a public plan nor should it be able to rivet an individual woman or her family from deciding they want to purchase mammogram coverage and i am deeply troubled that this bill which seems to be the larger context in which your work has been reported does precisely that i do want to say that it is important to chairman that facts be abided by and unfortunately in a piece of legislation this size it's subject interpretation and it's subject to quick review without people being very precise in their language i want to make it very clear i mean no personal offense by this but there have been things stated in this room today that are flat on true for example  the only way she option can be covered under the language of this bill is for two things to happen first the health care benefits advisory committee has to say contrary to what the bill says we think it should be covered and then the secretary has to say it so it's not a single decision by the secretary second and i'm sorry he's not here but the chairman of the full committee came and made an adamant argument which has been repeated several times here today that the bill prescribe minimum minimum benefits and therefore to say that coverage of mammograms is not prohibited is untrue that all the bill does is prescribe minimum that it also is flat not true if you go to page one sixty nine of the bill passed by the congress you will discover as i mentioned earlier that there are four levels of plan there is a basic plan an enhanced plan a premium plan and a premium plus plan the basic plan can only cover a zen be the things you recommend to be an a or a b it could cover a c if the two exceptions i just pointed out were to occur but the basic plan absent those two things happening does not cover anything but a's and b s but more important than that the definition of enhanced plan and the definition of premium plan both prohibit any additional benefit they say you can have an enhanced plan and you can have lower cost year and you can have a premium plan and it can have lower cost your ng but it can only cover the basic services so all three of the first levels of plans are prohibited from covering any service other than an a or a b only until you get the definition of a premium plus plan and i would point the chairman of the all committee to page one sixty nine lines twenty three twenty five does it say a premium plus plan is a premium plan that also provides additional benefits that's the only plan that can provide a benefit beyond the basic plan and therefore the first three levels of plans are prohibited from covering mammograms by law whether they're offered by the government or offered by a private insurance company whether in the public plan or in a private plan they are prohibited and that may not be the intent as the ranking member burton made very clear we need to deal not with what the and what the we need to deal with what the bill says and if it does not reflect our intent and i would hope in this case it doesn't because i don't think the government ought to be in the business of telling people you cannot buy coverage for mammograms then we need to fix the language of the bill or at least talk truthfully about it and the chairman of the full committee was wrong when he said that this sets only minimum there are words at the beginning of the bill which refer to a minimum but the words of the bills specifically say it can only cover those items with the exception of when both the secretary and the health benefits advisory committee decide to cover and i appreciate the opportunity to put that into the commission could add it to a basic benefit package was because when you made your opening statement you suggested that they that it couldn't be done that way that they couldn't include it so i mean i don't want to belabor the point i don't disagree with you cannot offer it and it cannot offer it absent extraordinary circumstances which are two other things i think we're saying i think and i think what we're doing we're saying the same thing but i'm not going to get into it i i don't think there's any you know i guess the task force can't fix these problems i'm here as a member of the task force speaking to the modified lines and speaking to the evidence we use to make them there clearly huge issues facing this country about health care and health insurance and health policy but i'm not an expert in that area if i could just add to the point it's clear that the provision of the maga screening for breast cancer extends life and so that's the service that we recommend  mean your recommendations talk about how for example forty to forty nine how it is important for women and their doctors to have to have a personalized plan with their trusted physician but there are many many women out there who don't have a trusted physician they don't they're not they're not receiving their check out certainly you all have message to women on the importance of taking personal responsibility and getting there not have access to care but but there are wonderful nonprofit groups where they provide well again i feel uncomfortable in being asked to put on a personal a personal how rather than my task force i would be remiss if i didn't encourage women to be interested in their health to take care of themselves but i'm here as a member of the task force to speak to the mammography guideline recommendations and not to go beyond my expertise i have friends who have no insurance my daughter is uninsured i know women who are uninsured and get can't get surgeries they need but that is not my role here my role here is to speak to the mammography guidelines to we have tried for a number of years to make our recommendations more risk stratified for breast cancer this has been perhaps a little more difficult than for some other topics like osteoporosis but again what i  with these recommendations is we would start having exactly this kind of discussion how do we find women who are extremely high risk how do we communicate with them effectively how do we make screening mammography something that is more individualized and tailor i would only add to that a plea for consideration of research of preventive services in the specifically specific populations under represented in screening and other prevention studies we often fail in this area and i will inform the committee that we have a discussion about health disparities associated with nearly every recommendation vote and the frustration on our point is the lack of evidence of africa in a specific trial aimed at high risk populations so i think this is a consideration of the task force and as we are evidence based this is a real plea on our part for research and funders of research to consider adequate studies that include disparate groups where we are concerned there may be differences and require different recommendation quickly and being a bit more sustained and maybe that's why we have time left many times i want to thank you all for your patience and your today and i really want to thank you for being here this is an issue that is of tremendous concern to us and as we look at what your findings that were and as we look at the language of the bills that are before us i think what we want to make certain we do is if there is offending language in the bill with want to get it down and of course we want to make certain that we have a clear understanding of what you brought forward and of your intent and i'm going to try to be  public and as you submit that vote who voted in hal one thing i would like for you to do for the record is also submit to us your science or evidence upon which you based these recommendations what was reviewed what study what findings what group if we can have that as a part of the record so that we can look at it i think that would be very instructive to us as we decide how to best move forward so i would like to ask you all to do them i'd also like to know what period of time how long did you spend on this how long was this up for discussion and under review what was  the thought process and the metrics that you worked from to come to this decision let us see a little bit about what you went through and how you went through it how you were quite your process  arrived at those decisions i do honestly believe that will be helpful to us with an understanding i will have to say i agree with some of my colleagues you probably stepped in to a bit of a quagmire did not expect well as unbelievable as it may seem to those who are so caught up in washington i was writing my biostatistics lectures and have been actually woefully naive  oblivious of what's been going on in the health care reform arena certainly from the point of view of specific statutory language in this now what i know is a two thousand page bill you know i knew nothing and quite honestly when i found out that these recommendations were being released the week of the vote that was the big vote i was sort of done and then also terrified and i think my being was completed prior to that the role of the taskforce might change under upcoming health care reform i will say that earlier this year we became aware of explicit well before that ok i appreciate that and i do thank you all for your sensitivity to this i think the linkage that existed with the language of changing your title and then giving credence in the force of law basically to the priority assignment that you would make is of concern to us and to our constituents i thank you all and i'm only going to yield back a second but i yelled at that mr chairman scientifically determined floor for preventative services in this bill i mean your understanding of your role you know i'm realizing that i really don't understand the bill should speak to the bill i've learned about the bill the bill itself does in fact that kind of power within the task force to develop a scientifically determined for other words a minimum threshold  under the basic coverage those recommendations then follow to the benefits advisory committee your recommendations will establish a floor under which the benefits advisory committee cannot go they can go higher however once the benefits advisory committee by the why where the benefits advisory committee consists of private medical doctors patients employers insurance experts a dentist and representatives of relevant government agencies it's chaired by the surgeon general once issues its recommendations the secretary those recommendations then are the floor the secretary then has the discretion to increase enhanced the coverage available in the basic essential benefits package once that has been established private insurers have the additional option of offering more coverage so the suggestion that because your task force has issued the recommendations that it has no insurance policies will cover mammograms for women in these categories even the suggestion that the essential benefits packages as established by this bill will not cover them is preposterous there's no truth in it and i do have a specific question i'd like to ask you  regarding some confusion that your findings have created back home in my district there was a recent letter to the editor the editor very widely distributed regarding your  findings that have created some confusion i'd ask that you try to clear this up for us the author of this letter writes what's more this is a quote what's most troubling about the federal panel's recommendations is that they're based mainly on cost saving and of quote she also expresses concern that the recommendations are quote cost saving measures and of quote can you tell us today in the uncertain terms what the role of cost of mammograms played in your investigation and finding this is an easy question cost played no role in our recommendation again and i've said it publicly in other settings and i'll say it again here i think i've said it three times here cost was not a consideration the voting of our recommendation thank you when and finally  author of that same letter pointed out that the task force contains quote no cancer specialist and quote this is obviously a point that would be disconcerting to many is it true  at no members of the preventative task force have any experience in working with cancer that is incorrect members of the task force consist of myself i was the vice chair  national cancer policy board one member is a member of the national cancer institute board of scientific councilors another member current member is a professor of law to he's the director associate director them to make the kinds of recommendations they made within the arena of screening and preventive services thank you doctor i yield back my time thank you the gentleman from texas mr green  know we can't want to welcome our doctors and i guess having served on this subcommittee for twelve years now and the release from the u s p t s probably got more coverage than anything our subcommittee's done except the health care bill and and there was a lot of misinformation about it but in your testimony you say that individuals representing the views of the american pointed out there were two members of the american college of obstetrics and gynecology on the panel they were official a cog reviewers were official reviewers ok they made a number of comments one of their comments which was the most substantive comment in retrospect was about the missed their anticipation of a misperception of r c recommendation and they were right and we should have listened more carefully to them and i'm sure we will listen more carefully in the future and i think there is misinformation i guess on on the self exam the information and from what your testimony earlier was that you know physicians need to be able to provide the expertise on so women can do the self exam that's not perfect if there's a question that they ought to talk to their physician and that's where it goes from there so that's why i don't understand the fear of the  last question is a major concern i have is the lack of transparency of the process within the u s p s for deciding whether or not to change or create new screening recommendations and depending on what happens with a health care bill your initial  decision could make a big difference how could the task force be more open to outside input and feedback and what changes would you make in the future after what you've learned from this experience thank you for this question the task force understands the criticisms regarding transparency as our profile has been increased during the discussion of health care reform we believe it is incumbent upon us to increase our transparency in such a way that people understand as previous congresswoman asked how we get to the decisions that we get to the task force is already working on new transparency approaches including allowing internet based public comment on different work products we think that's a good step we are cautiously trying to expand in the areas of transport transparency to include  potentially public commentary during meetings and other approaches that we believe meets the intent and the requirement for transparency so that the decisions are made in such a way that we're not spending time in front of the public trying to help people understand the processes so we understand this criticism we actually started working on enhancing transparency about a year and a half ago and  i will i will only tell the congressman that our slow working has to do with understanding the resource impact of becoming more transparent but we absolutely believe we need to do it and we're working towards that is thank you chairman thank you and i think that concludes our questions but let me just thank both of you really i think that you did a tremendous job today of clearing up a lot of misunderstandings and  as someone who's been in politics i guess i could say my entire life i think it's kind of refreshing to find out that you know you really were very independent and not at all aware what we were doing  think we give ourselves too much importance you know we we all think we're so important everybody's paying so much attention to everything we do kind of refreshing to know that you were not i think you and i last the next  let me welcome our second panel and introduce the panel beginning and my left is dr otis webb brawley who is chief medical officer for the american cancer society and next is jennifer alert lurie the re the re who is president of the susan g komen for the cure advocacy alliance and then we have dr donna sweet who is a member of the american college of physicians clinical assessment efficacy subcommittee and finally fran biscoe who is president of the national breast cancer coalition i know some of you have been here before and thank you for being here you know i  won't repeat that we have the we have sheets to keep your comments if you can to five minutes they become part of the record and if you want to you can submit additional written comments later but let's start with dr brawley thank you good afternoon mr chairman and distinguished members of the committee imo to sprawl the the chief medical officer of the american cancer society on behalf of the eleven million patients and survivors in america today the society thank you for your continued leadership  fight against cancer and your commitment to enacting comprehensive health care reform legislation this year i appreciate the opportunity to testify about the important role mammograms play in combating breast cancer deaths as a medical oncologist who actually treats breast cancer patients and treated hundreds of breast cancer patients in my career and i have observed firsthand and the heartbreak this disease has on women and their families over the years i've also witnessed the advances we've made in breast cancer early detection and treatment advances that have led to fewer women suffering and ultimately dying from this dreaded disease i can't help but note that in our current system our society prohibits a large number of women thirty to forty percent of those who should be getting mammograms from actually getting mammograms i also have to note that my own research published inside it before this committee before has shown that uninsured women of the same stage have poor survival compared to insured women of the same stage that is to say that even when early detected insurance is a prognostic factor in breast cancer mr chairman as you know the society in recent weeks has publicly disagreed with the recommendation of the u s preventive services task force with respect to mammography let me say right now that i have tremendous respect for the task force as an academic physician i look forward to virtually everything that the task force has published over the last twenty years regarding cancer i also want to say that reasonable experts can look at the science and disagree there is useful screening that should be done and use less screening that actually can be harmful and that is something that the task force i think should be looking at in an objective fashion and actually is generally done a very good job of doing with respect to mammography the scientific evidence supporting its value in reducing deaths from breast cancer is quite strong in looking at the evidence the society along with other medical groups believe that screening mammography offers an identifiable important survival benefit to women any age group forty to forty nine and indeed women age forty and above more specifically the society believes that there would in mortality and less invasive treatments associated with early detection of breast cancer using mammography continues to warrant a recommendation of annual screening for all women beginning at the age of forty we do agree with the task force that women should be informed of the potential risks as well as the potential benefit of the procedure the data and literature examined by the task force in the lead up to its november announcement mammography is essentially the same data reviewed by an expert panel of breast cancer research as clinicians and epidemiolog convened by the american cancer society in two thousand and three however in that earlier review of the society's panel considered the additional findings of a population based study of modern mammography which showed much stronger benefits from screening compared with the more limited data examined by the task force translated we actually think there's a greater benefit to the mammography screening than does the task force in addition since that time a number of advancements of a marriage that have shown to increase the effectiveness of mammography for women aged forty to forty nine there been improvements in the quality of mammograms resulting from the mammography quality standards act in q s a there's been a shift to using digital mammograms overfill mammograms which research indicates may be more effective in screening younger women with denser breasts the introduction of new technologies such as magnetic re also proven to be a particularly effective tool in high risk women let me be very clear on the next point we understand and acknowledge that mammography screening is not a perfect test indeed it is an imperfect test but we also believe that this imperfect test is the only good test other than awareness of one's breast to help save lives at this time we can and we must invest in research to find better tools for detecting and treating breast cancer women deserve a better test than mammography indeed one of the great problems right now is there's a certain complacency or satisfaction with the use of the ma gra in women of all ages we need a better test the essential fact right now is mammography is one of the two ways that we can use to save lives i have to note that this ballot talk about breast self examine as a medical oncologist an epidemiologist who is involved in screening and reads the screening literature and the doctor who treats let me say that we've been talking past ourselves when we talk about breast self exams today breast self examination shown in the medical literature and spoken against by the task force is a woman doing a specific regimen an exam once a month that actually would take about twenty to thirty minutes for a woman to do what most of us including the american cancer society have done is move away from that regimen it breast self exams which was advocated twenty to thirty years ago toward something which is a little bit different which is women being aware of their breasts and sensually being aware of their breasts and looking for differences in their breasts on an almost daily basis this is called breast awareness most women indeed find their breast cancer through breast awareness not breast self exams there are two randomized clinical trials that show that breast awareness and breast self exams are equivalent in terms of mortality reduction but breast self exams actually increases the number of unnecessary biopsies done versus breast awareness so i prefer to advocate breast where in this i will note also serve it approximately thirty to forty percent of american women aged forty and up currently not getting regular mammograms in the united states about half of all women diagnosed with breast cancer actually are diagnosed through this breast awareness and not through mammography for many of the women who cannot get mammography this is the only way that they can actually have any type of early detection and summing up we know we can do better and with your help mr chairman we're heading in the right direction the affordable health care for america act recently passed by the house will improve health care and it provides a significant investment in cancer prevention your two and a half minutes i'm sorry we strongly support the changes you've made in the legislation that will help the task force improve the transparency and inclusiveness of its operations but let me just stop at that point and say thank you for asking them to appear here thank you this  letter thank you mr chairman mr ranking member and members of the committee thank you for the opportunity to testify about the recommendations of the u s preventative services task force my name is jennifer and i'm president of the susan g komen for the cure advocacy alliance and i behalf of the patients survivors scientists clinicians and advocates of the common family thank you for holding this hearing and i also want to thank the previous taskforce witnesses for their honesty and how discussing how this was communicated to the public let me begin by stating that breast cancer experts agree far more than they disagree this is a point that we have stressed since the task force recommendations were first released there is no debate the mammography reduces the risk of dying from breast cancer only debate over the timing and frequency of the margraf we don't want women to react to this latest controversy as a reason not to get screened komen in consultation with our scientific advisory board is not changing our screening recommendations at this time we continue to recommend that women be aware of their breast health understand their risk and continue to follow existing screening recommendations including mammography beginning at age forty for women of average risk and earlier for women with known risks of breast cancer as you can imagine komen affiliates have been inundated with concerns that the task force recommendations could lead to impediments to mammography many comments have come from breast cancer survivors who were diagnosed before the age of fifty this is a very typical one i was forty six years old when i went in for my annual mammogram like so many other women there is no history of breast cancer in my family i was stage two and if i had not if not for the mammogram i would have had much more advanced cancer we know that mammography is an imperfect tool but instead of stepping away from it we must close the technology gap and come up with better methods that's why komen is funding promising screening research we must work together government private industry doctors and patient advocates to deliver screening technology that is more predictive and personalized but less expensive next year komen will host a national technology summit and we ask to help us prepare by reporting on investments that they've made in screening technology but let us also redouble o efforts on behalf of the one third of women some twenty three million american women who are not being screened due to lack of access education or awareness we partner closely with the c d c s national breast and cervical cancer early detection program to fund free clinics and mobile vans yet the g a o found that over half of eligible women for this program do not receive screening that's a disturbing finding that underscores the need for access to affordable insurance to eliminate health disparities and that's why coleman supports the valuable patient protections in h r thirty nine sixty two that would increase access to affordable health insurance prevent insurance companies from denying coverage due to preexisting conditions protect patients from high out of pocket costs and increase access to mammography screening in light of the new task force recommendations however we must ensure that women ages forty to forty nine will have access to the same coverage  car sharing benefits as women age fifty and older even a relatively small co payment reduces mammography rates we do understand that h r thirty nine sixty two will create a new entity which would not be bound by the t forces guidelines and that the bill does not exclude from the minimum benefits package services that are not rated a and b we understand that the task force recommendations are a floor not a ceiling but our bottom line is that women in the forty to forty nine age group may after consulting with their doctor choose to forgo a minor mammogram but those who do choose to have one must have access to it on the same terms as women age fifty and older the komen advocacy alliance is pleased that h r thirty nine sixty two includes patient representatives as advisors to the task force on clinical preventative services we believe that patient advocates can help to develop and deliver effective messages about prevention and screening we hope that these past few weeks of confusion will ultimately result in women taking more interest in their breast health that many more under served women will be screened and that an intensive effort to make breakthroughs in screening technology will begin anew thank you mr chairman thank you dr sweet good afternoon and thank you chairman for this opportunity i'm donna sweet a general internist and i'm pleased to present the testimony of the american college of physicians i'm a member of the peace conical efficacy assessment subcommittee which oversees the development of a c p s evidence  guidelines and i provide also comprehensive medical care to hundreds of patients in the state of kansas because a c p does not comment on the guidelines issued by other organizations i'm unable to express an a c p opinion of the task force recommendations but i can speak to the college's own guidelines on screening mammography and women between ages forty to forty nine years which was published actually in two thousand and seven we recommend that clinicians should perform individualized assessment of risk for breast cancer to help guide decisions about screening mammography inform women about the potential benefits and harms of mammography and based greening the margraf e decisions on benefits and harms of screening as well as a woman's preferences and her own breast cancer risk profile the purpose of a clinical guidelines is to facilitate an informed and educated discussion between the patient and her trusted clinician so that together they can decide on a personalized plan of screening diagnosis and treatment not all women between forty and forty nine have the same risk for breast cancer factors that increase the risk include older age family history of breast cancer older age at the time of first birth younger age men are can history of breast biopsy in my own practice i use a s guidelines to engage my female patients in a discussion explain that mammography although a potentially valuable tool to screen for breast cancer is an imperfect one for some patients it will detect cancer at a more treatable stage it can also lead to false positives which can lead to biopsies scarring and potential infection you can leave false negatives that is mammography does miss cancers it may result in aggressive treatment of cancers that may never have become life threatening just in the past three days i've had three different patients coming to see me who have been extremely confused over this whole issue i was able to speak to each woman's risk profile and discuss with them the benefits and possible harms of getting a mammogram one was a sixty six year old patient roldan medicare who had come in for her routine visit for hypertension and clearly misunderstood most of the debate she has a history of a sister with breast cancer we have been doing yearly mammograms and she was worried that i was not going to let her get a yearly mammogram because of these new recommendations another seventy one year old came in and she wanted to get her mammogram which was scheduled in february before january first why she picked that date i don't know because she believed that the government would soon stop her from being able to get a mammogram and she didn't want that to happen i was able to reassure her that i did not think mammograms would be rationed the third however was a very good discussion a forty six year old woman whose mother had breast cancer she wanted to discuss her own risk and actually was wondering if she had to have yearly mammograms i was able to communicate to each of them that in them they did need you a mammograms that we did not do things from a cookie cutter women should not be treated all alike in all three cases as i said they did and will get their yearly mammograms but based on their individual risk factors and a discussion of why the controversy over the breast cancer screening guidelines give physicians the opportunity to educate their patients on the importance of evidence based guidelines to help them make the best choice for them it also has important lessons for policymakers one is that the public is ill served when assessments of clinical effectiveness are politicized the u s preventive services task force is a highly regarded credible an independent group of a spritz differences of opinion on the task force recommendations should be openly discussed but it's not constructive to undermine public confidence by making ill founded attacks on the integrity credibility motivations and expertise of the clinicians and scientists on the task force such politicization if left unchallenged could result in future assessments being influenced by political or stake interests instead of by science second the concerns of the public is misled by some into believing that cost was behind the task force recommendations according to our the task force does not consider economic costs in making recommendations third the public needs to understand that when health plans make decisions on covered benefits they consider many different issues of which the evidence based guidelines are just one under the bill passed by the house health plans generally will be required to cover preventive measures for which  newly constituted taskforce on clinical preventive services have given an a or b no limits replace though on health plans ability to provide benefits for other preventive services and to consult with other sources in making such determinations rather than limiting access to prevention my patients will benefit from having a floor not a limit on preventive services all health insurers will be required to cover usually with no out of pocket cost to them and perhaps even more importantly has been said here today many times millions of women who have no access to health insurance will now have coverage and the ability to actually get screening mammograms fourth we need to communicate information to the public in a way that facilitates an understanding of how evidence based effectiveness review support not supplant individual decision making by patients and their clinicians they should be informed that they have the right to know about the current best evidence on the benefits and risks of different treatments and interventions my patients have the right to know that physicians will offer intervention shown to positively impact health and patient outcomes and they have a right to know that we will not recommend intervention show not to provide any benefit and possibly cause harm patients have the right to be treated as individuals with their own unique values and personal risk risk characteristics instead of being asked to follow a one size fits all treatment protocol and they have the right to know that the evidence comes from respected independent and credible clinicians and other scientists protected from political and other stakeholder pressure and i thank you for this opportunity thank you doctor this go thank you i'm friend the scope president of the national breast cancer coalition a twenty two year breast cancer survivor as you know n b c c is a coalition of hundreds of groups from around the country dedicated to our mission to end breast cancer one of our roles is to train advocates to understand the process concepts and language scientific research we analyze scientific information for our members in the public from the perspective of lay advocate our number one priority for many years has been guaranteeing access to quality health care to everyone we believe we cannot achieve our mission without it we've been working with congress and the administration on this goal based on our framework for access to quality health care developed over a number of years of hard work by our grassroots leadership and a key component of that framework is making certain that trained consumers have a seat at every table where decisions are made on health care policy we believe in evidence based approaches to health care as a key to quality care so what is the evidence behind mammography screening as we are all well aware and as many people have said mammography is significant limitations and there has been much controversy over the years about screening programs and what age are they effective how  balance risk and benefits how can we communicate the very real limitations of screening and the harms associated with that in one nine hundred ninety seven and i h consensus conference recommended against routine screening of women under the age of fifty the political and outside organizational pushback not evidence to repeated that recommendation so in fact we have known the issues with screening for decades we also know that forty thousand women will die of breast cancer this year tens of millions of people in this country are uninsured many many millions like to access to quality care we know we have a great deal of work to do to fix this situation we know the breast cancer is a complex disease that while we have learned more about the biology of the disease in the four decades since mammography screening programs have been instituted we have not yet learned how to detect life threatening breast cancer at a point where we can make a difference how to cure it for every woman how to prevent it given all of this we were frankly stunned at the reaction of the media and many in the cancer community and in government to the task force recommendations the task force is a body of the right experts who look carefully at updated evidence and objective we made recommendations not that different from their prior recommendations given all of this the amount of time and attention given to these revised recommendations seems just a bit unseemly the public has increasingly put their faith in screening and early detection even though we've never had good evidence that this would have a significant impact but too many did not want to highlight the known limitations of mammography they wanted simple messages once a year for a lifetime early detection saves lives the overemphasis on the importance of screening because some people to state over and over again that mammograms prevent breast cancer and please be very clear mammograms do not prevent breast cancer we had hoped at the task force recommendations would cause all of us to stop and think about screening take the time to look carefully at the evidence and put screening and its limitations into proper perspective and that can still happen it's important also to put this in the context of the population where screening screening programs are for a healthy population for the millions and millions of women the vast majority of whom will never get breast cancer the question then is how we do devise a screening program that appropriately balances risks and benefits for these healthy women so what did this half force actually say to women in their forty's they said there are benefits and harms from mammography screening that you should know about and you should make an individual decision at what age you will begin a screening program so the task force actually recommends giving women control over their own health care decision on self examination dr brawley pointed out that the self examination touched on by the task force is that routine regimented monthly search for cancer it has been represented as saying that women should know their bodies of course they should this isn't about that some are concerned that the new guidelines will prevent under served women from entering the medical system at all and we would counter that the solution to that is to enact universal access to health care for all not to depend on a faulty to radiation and the risks of false positives in order to get them to a doctor disadvantage women deserve the same access as all other women to quality evidence based care and the right information we do need to more move forward because none of this is good enough for women we can use this and we should have used this as an opportunity to educate the public about science about evidence based care to help  feed some argue that public health messages need to be simple and changing guidelines will confuse women we would argue that while message need to be simple they need to be truthful women deserve the facts we've all heard from women over the past month who are outraged and who believe that a mammogram saved their lives these anecdotes are not evidence they may be compelling soundbites great media stories but they're not evidence on which we should base this nation's public health agenda that should be based on the type of scientific work done by the task force we can't believe in science only when we like the answers it produces i want to end with an anecdote  was the executive vice president of the national breast cancer coalition and her breast cancer was detected early in her late thirty's probably was not life threatening and she had treatment she died this past june as a result of her treatment her story and all of the anecdotes just tell us how little we know about breast cancer how we need to be so very careful about evidence and push for the right answers no matter how unhappy we are with what those answers are let's save our outrage for the reality that we know too little and women deserve so much more thank you thank you and when i will try to get this done before the votes i don't know if that's possible because i start with myself you know i really want to apologize to you not you know maybe on behalf of congress if i could do that because you know i was listening to what dr sweet said in your absolute right that this has been totally politicized and i guess you know the problem is that you know congress is political and maybe this isn't the you know the vehicle for i mean it's sort of interesting to see that in the first panel most of the members are here and the most of the media we're here now are on the second panel which is not the political panel and situation is reversed you know and doctor ms this goes talked about how essentially and i don't want to put words in your mouth but you know after listening today i was i can't help but say i'm not sure there really was that much of a difference between what the task force said now versus you know what the recommendation was a few years ago or even between what you're saying and the previous panel said it's just it's just amazing how you know these differences if there are any have been exaggerated and politicized but i i guess that's just the nature of the process around here so i don't know what i don't know what we can do about it or make it any different let me live and i and i say that you know out of sadness really but let me issue just a couple questions because i know the time is running out here and i'll start with dr brawley brawley and a lerner a few days after the test for its recommendations the cancer society issued a statement urging that health care reform create a transparent and evidence based process for making task force recommendations and i guess coleman  echoed those concerns but your statement dr brawley listed a number of changes you'd like to see in health reform and you discussed the importance of transparency and the task force this process of arriving at its recommendations now i believe that the bill h r three nine six two actually addresses those concerns so i wanted you to really you know answer that i mean the the this importance of stakeholder input and those recommendations you made about that do does the bill h r three nine six to address those concerns well sir i believe that it does i think the most important thing is that the task force continue to provide objective evidence but also provide the objective evidence and open arena where people can actually see the process ok and then there's a right for commons perspective do you agree that that the provisions in h r three nine six two would improve the task force recommendations process i mean you don't have to just say yes or no but go ahead sir actually yes i mean h r thirty nine sixty two has a stakeholder panel that would advise the new clinical services task force and we think that makes a lot of sense we think such a panel i think could have helped to really communicate the findings of the task force and even though people might not have there still may have been disagreement within the scientific community i think the message could have been delivered in a way that was much more helpful to women and their providers well i want to thank you i just was trying to make the point really that the the the issues that the american cancer society and komen raised months ago well before these tests or its recommendations emerged you know with that we felt that on the house side we were listening to and i and i'm trying to point out that as a result of your efforts  this collaboration you know that the bill contains the changes to the task force necessary to improve the process that was my only point and then the second one and i'm going to ask all of you this quickly and that is as you know my colleagues on the republican side have replete with repeatedly raised concerns about the house passed health reform bill in light of the of the task force recommendations and they've repeatedly asserted h r three ninety six to somehow well i don't want to put words in their but i think there's the suggestion that somehow the bill you know is a step backward on the issue of breast cancer or breast cancer screening so i just want to ask each of you is you know on the whole do you think the house passed health reform bill h r three nine six two is actually more helpful or is a step forward or a step backward with regard to women with breast cancer in the screening is and i'll give you to comment on that briefly mr chairman if i can just say there are thousands of american women who died today because of lack of access there are thousands of women who die today because they hear i detected early but they don't have insurance t get access to reasonable and good care any effort that gets those people reasonable and good care is a good the effort is going to save lives we've been talking about the number of lives that would be lost to this recommendation  maybe it was a recommendation not to get screened for women in their forty's maybe it wasn't but the number of lives that we could just picks that we could just say to a logistical fix is tremendous just get them access to right i would add in addition to the universal access that dr brawley mentioned also the limitations on preexisting conditions and out of pocket costs are currently a huge burden for breast cancer patients and one of the main items that our advocacy community throughout the country asked that we followed very closely in health care reform and those protections are included in h r thirty nine sixty two doctors thank you absolutely this bill will help the health of american women with and without breast cancer there are number of women who managed to get diagnosed and then have no access to reasonable care as dr said the number of women even in my own practice that are locked into jobs that they would rather not stay in they can't move because of lack of health insurer ability they know if they leave their job and leave their health insurance when they try to get the next one they're going to be uninsurable and i think the fact that this bill addresses getting rid of preexisting conditions and guaranteeing health insurance to all that are reasonable cost is extremely important and then the third thing is the bill does address some of the health care workforce issues access means having a trusted clinician as the woman from florida said and there are not enough of the primary care people out there anymore to be trusted clinicians for all the people we're going to give access to and your bill does put in provisions to have an improved i think primary care workforce by improving payment and other things so i think this bill is an absolute improvement the millions of lives that we lose because a true lack of health insurance is much much greater than what we're going to lose by a few women who decide not to have screening once they think about it thank you well as you know mr chairman the national breast cancer coalition has endorsed the bill the house bill and we completely support it we believe it is incredibly important tool in eradicating breast cancer we think it will move us forward tremendously in getting everyone access to health care and helping save lives from breast cancer and i hope that this controversy does not cause the congress to interfere in any way with the independence and objectivity of the task force we cannot allow that to happen we need evidence based quality care and i also truly wanted to ask the question that if the bill was changed to mandate c level recommendations in the basic benefit package if everyone who spoke to that issue today would then support the bill i tend to doubt that so i really think that if we want to stabilize if we want to move fo if we want to win breast cancer we need guaranteed access to health care reform in the house bill is very important to achieving that and thank you let me mention i was under the impression we had votes in fact for in recess on the floor so there's actually not any real time constraints here chairman ding have on health plans is a requirement that preventive measures for which the task force has been given an a or b grade b cover the bill does not give the task force of the federal government itself any authority to put placed on their ability to consider recommendations from sources other than the test for making such cover recommendations now if you please starting with your dr brawley do you agree congressman as i said in my testimony we also see that the role of the task force is creating more of a floor than a ceiling so in that sense i would agree with you our viewers are doctors for it you agree and i have some the provisions that we're discussing today or any other part of this legislation will trigger a nasty program of rationing health care now dr no  secretary clinton in the joint chiefs of staff in the foreign affairs committee talking about afghanistan so although this is such an important issue for the district i represent i represent a majority hispanic district that is also a federally medically underserved area and we face many many issues when it comes to encourage to encourage women to seek primary and primitive care services we rely on our county hospital district in our community based health clinics provide the services and screening for our constituents i worry that the revised recommendations was the safety net for riders from aggressively educating screening for breast cancer in these under served populations often say we have one of the premier medical centers in the world including in the anderson cancer center located in our backyard but my constituents can see the medical center it's hard for they will get there because they're substantially uninsured you know unfortunately unfortunately most do not have the access to the medical services  could you briefly speak about the current access assessed access barriers for breast cancer screening minority and those residing in medically underserved districts face and what impact these recommendations may have on these populations congressman and i hope the recommendations of the task force will have very little effect on your constituents with the except perhaps the discussions that we've had in the news over the last few weeks will bring breast cancer much more to the forefront i have some hope i said in my testimony about half of all women in their forty's and fifty's who are diagnosed with breast cancer are actually diagnosed now through a traditional breast self exams but what we prefer to call breast awareness day notice when you're getting dressed or when you're in the shower that sort of thing perhaps people will hear what this national conversation we've had and actually be a little bit freer to come forth and get evaluated by a doctor should they find i also hope that people will continue listening to the other organizations like the american cancer society that have said that women age forty and above should continue getting mammography on an annual basis but also i think it is important to realize that there is controversy about how good mammography is and as i'll just leave one last statement mammography is imperfect but right now it is the best technical tool that we have other than awareness for early detection so mammography is much more valid than the p s a test is for the most oh yes absolutely you are absolutely correct there are nine studies in the literature the show that mammography saves partner closely with the c d c and other providers to support free clinics in mobile vans and districts such as yours and so we're very familiar with the kinds of constituents you haven't and really a very relationship they have with the health care system many of whom are unsure uninsured and so we've been working very hard in these last few weeks to make sure that the  release of this recommendation doesn't cause women who really already have that fragile relationship who may just be coming into mammography clinics for the first time in their lives to say well gee maybe i don't need to come at all so we're working very hard to ensure that that that message doesn't get twisted around and be taken as as a sign that mammography can provide help to them and i would hope as  clinician doing this just as in my practice women will come in talking about it there is nothing more likely to get a patient to bring something up than to see it on c n n or in the controversial position and maybe you will sort of nudge many of our clinicians who perhaps haven't taken the time to have that discussion to actually make it an individualized personalized discussion with that woman about what she needs along with the fact as we said earlier that many many many of those women if health care reform can occur and we do have access to health insurance for the poor and the people who need it the most we will be able to offer screening to some of these women in a clinical situation that have never had that available so i truly see this is a critical time and the whole blue it is a political sort of system and there's a lot of things out there that just aren't true i think but it does bring women to discuss it and once they bring it up then the doctor or the clinician has to follow through i think yes we are working very very hard on making certain that everyone in this cat country has guaranteed access to quality health care and that will certainly solve the problem we're spending the majority of our resources on that issue there are also a number of studies out there looking at what are the barriers to access for under served population why do they not access the health care system and of one of the reasons is because they don't have coverage for treatment that's why the national breast cancer coalition a number of years ago worked very hard to get enacted into law this c d c breast and cervical cancer treatment act because we knew that screening even if you do get a mammogram you have to have access to treatment if you want to save a life and so that is our number one concern and that is where we focus most of our work thank you chairman no matter time it's pretty shaky my concern about the furor over this is that women will make that decision not to and again early detection is still the answer and particularly in underserved communities thank you mr and thank you and i think that concludes our questions i just want to thank all of you again and you know once again as i said to the previous panel you certainly cleared up a lot of the misconceptions i just hope we can get that message out to the media which is often difficult but thank you and we you may some of the members may submit written questions and we try to get those to you within the next ten days so you might get some additional questions and course the clerk would notify you you know that and you know the time period to get back to us but i do want to thank you thank you again and without objection this meeting of the subcommittee is adjourned thanks