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74–856 2012

BREAST CANCER SCREENING RECOMMENDATIONS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

DECEMBER 2, 2009 

Serial No. 111–85 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 


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COMMITTEE ON ENERGY AND COMMERCE 

HENRY A. WAXMAN, California, Chairman 

JOHN D. DINGELL, Michigan 

Chairman Emeritus 

EDWARD J. MARKEY, Massachusetts 

RICK BOUCHER, Virginia 

FRANK PALLONE, JR., New Jersey 

BART GORDON, Tennessee 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

BART STUPAK, Michigan 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

Vice Chairman 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANE HARMAN, California 

TOM ALLEN, Maine 

JANICE D. SCHAKOWSKY, Illinois 

CHARLES A. GONZALEZ, Texas 

JAY INSLEE, Washington 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

CHARLIE MELANCON, Louisiana 

JOHN BARROW, Georgia 

BARON P. HILL, Indiana 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

CHRISTOPHER S. MURPHY, Connecticut 

ZACHARY T. SPACE, Ohio 

JERRY MCNERNEY, California 

BETTY SUTTON, Ohio 

BRUCE L. BRALEY, Iowa 

PETER WELCH, Vermont 

JOE BARTON, Texas 

Ranking Member 

RALPH M. HALL, Texas 

FRED UPTON, Michigan 

CLIFF STEARNS, Florida 

NATHAN DEAL, Georgia 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOHN B. SHADEGG, Arizona 

ROY BLUNT, Missouri 

STEVE BUYER, Indiana 

GEORGE RADANOVICH, California 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

(II) 


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SUBCOMMITTEE ON HEALTH

FRANK PALLONE, JR., New Jersey, Chairman 

JOHN D. DINGELL, Michigan 

BART GORDON, Tennessee 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

JANICE D. SCHAKOWSKY, Illinois 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

JANE HARMAN, California 

CHARLES A. GONZALEZ, Texas 

JOHN BARROW, Georgia 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

CHRISTOPHER S. MURPHY, Connecticut 

ZACHARY T. SPACE, Ohio 

BETTY SUTTON, Ohio 

BRUCE L. BRALEY, Iowa 

NATHAN DEAL, Georgia, 

Ranking Member 

RALPH M. HALL, Texas 

JOHN B. SHADEGG, Arizona 

STEVE BUYER, Indiana 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

MIKE FERGUSON, New Jersey 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 


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C O N T E N T S 

Page 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 1 

Hon. Roy Blunt, a Representative in Congress from the State of Missouri, 

opening statement ................................................................................................ 3 

Hon. Henry A. Waxman, a Representative in Congress from the State of 

California, opening statement ............................................................................. 3 

Prepared statement .......................................................................................... 5 

Hon. John Shimkus, a Representative in Congress from the State of Illinois, 

opening statement ................................................................................................ 9 

Hon. Anna G. Eshoo, a Representative in Congress from the State of California, opening statement .................................................................................... 9 

Hon. Michael C. Burgess, a Representative in Congress from the State of 

Texas, opening statement .................................................................................... 10 

Hon. Lois Capps, a Representative in Congress from the State of California, 

opening statement ................................................................................................ 12 

Hon. Phil Gingrey, a Representative in Congress from the State of Georgia, 

opening statement ................................................................................................ 17 

Hon. Donna M. Christensen, a Representative in Congress from the Virgin 

Islands, opening statement ................................................................................. 18 

Hon. Joseph R. Pitts, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 19 

Hon. Kathy Castor, a Representative in Congress from the State of Florida, 

opening statement ................................................................................................ 20 

Hon. Mike Rogers, a Representative in Congress from the State of Michigan, 

opening statement ................................................................................................ 21 

Hon. Janice D. Schakowsky, a Representative in Congress from the State 

of Illinois, opening statement .............................................................................. 22 

Hon. John B. Shadegg, a Representative in Congress from the State of Arizona, opening statement ...................................................................................... 22 

Hon. John P. Sarbanes, a Representative in Congress from the State of 

Maryland, opening statement ............................................................................. 24 

Hon. Marsha Blackburn, a Representative in Congress from the State of 

Tennessee, opening statement ............................................................................ 25 

Hon. John D. Dingell, a Representative in Congress from the State of Michigan, opening statement ....................................................................................... 25 

Prepared statement .......................................................................................... 28 

Hon. Joe Barton, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 30 

Prepared statement .......................................................................................... 32 

Hon. Gene Green, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 36 

Hon. Sue Wilkins Myrick, a Representative in Congress from the State of 

North Carolina, opening statement .................................................................... 37 

Hon. Tammy Baldwin, a Representative in Congress from the State of Wisconsin, opening statement ................................................................................... 38 

Hon. Diana Degette, a Representative in Congress from the State of Colorado, 

opening statement ................................................................................................ 39 

Hon. Zachary T. Space, a Representative in Congress from the State of 

Ohio, opening statement ...................................................................................... 40 

Hon. Betty Sutton, a Representative in Congress from the State of Ohio, 

opening statement ................................................................................................ 41 

Hon. Bruce L. Braley, a Representative in Congress from the State of Iowa, 

opening statement ................................................................................................ 42 


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VI 

Hon. Ed Whitfield, a Representative in Congress from the Commonwealth 

of Kentucky, prepared statement ....................................................................... 149 

WITNESSES

Ned Calonge, M.D., M.P.H., Chair, U.S. Preventive Services Task Force .......... 43 

Prepared statement .......................................................................................... 46 

Diana B. Petitti, M.D., M.P.H., Vice Chair, U.S. Preventive Services Task 

Force ...................................................................................................................... 60 

Prepared statement .......................................................................................... 46 

Otis Webb Brawley, M.D., Chief Medical Officer, American Cancer Society ..... 86 

Prepared statement .......................................................................................... 90 

Jennifer Luray, President, Susan G. Komen for the Cure Advocacy Alliance ... 101 

Prepared statement .......................................................................................... 103 

Donna Sweet, M.D., M.A.C.P., Member, American College of Physicians’ Clinical Assessment Efficacy Subcommittee ............................................................. 111 

Prepared statement .......................................................................................... 114 

Fran Visco, President, National Breast Cancer Coalition .................................... 134 

Prepared statement .......................................................................................... 137 

SUBMITTED MATERIAL

Letter of December 4, 2009, from the U.S. Preventive Services Task Force 

to Members of U.S. Senate .................................................................................. 14 


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BREAST CANCER SCREENING 

RECOMMENDATIONS 

WEDNESDAY, DECEMBER 2, 2009 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON HEALTH, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:07 a.m., in Room 

2123 of the Rayburn House Office Building, Hon. Frank Pallone, 

Jr. [Chairman of the Subcommittee] presiding. 

Members present: Representatives Pallone, Dingell, Eshoo, 

Green, DeGette, Capps, Schakowsky, Baldwin, Matheson, 

Christensen, Castor, Sarbanes, Space, Sutton, Braley, Waxman (ex 

officio), Shimkus, Shadegg, Blunt, Pitts, Rogers, Wilkins Myrick, 

Burgess, Blackburn, Gingrey and Barton (ex officio). 

Staff present: Ruth Katz, Chief Public Health Counsel; Purvee 

Kempf, Health Counsel; Sarah Despres, Health Counsel; Jack 

Ebeler, Health Advisor; Stephen Cha, Professional Staff; Anne 

Morris, Professional Staff; Bobby Clark, Professional Staff; Alvin 

Banks, Special Assistant; Elana Leventhal, Professional Staff; 

Katie Campbell, Professional Staff; Virgil Miller, Professional Staff; 

Andy Bindman, Robert Wood Johnson Fellow; Ryan Long, Minority 

Chief Health Counsel; Brandon Clark, Minority Professional Staff; 

and Chad Grant, Minority Legislative Analyst. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. The subcommittee is called to order, and I will 

first recognize myself. 

The subcommittee is meeting today to review the new breast cancer screening recommendations issued by the U.S. Preventive Services Task Force just a few weeks ago. By now, I am sure everyone 

in this room is familiar with the new guidelines or at least we are 

familiar with the controversy surrounding them. From what I have 

heard from my constituents, friends, family members and academic 

institutions in my district, there are a lot of questions, frustration 

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 am holding this hearing 

today. It is time for all of our questions to be answered. We want 

a clear understanding of what the report did and didn’t say and 

what others have to say about the report. 


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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 have invited the U.S. Preventive Services 

Task Force to speak directly about their work. It is 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. We 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 force’s 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 

with 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. It has led to treatments and 

cures for diseases once considered a death sentence, and it is 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. These studies should be one of many 

tools. Patients and their doctors should have access to as much information as available. They should have informed conversations. 

But the decisions about mammography for women in their 40s 

should remain with women and their doctors. 

There is 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 while at 

the same time others have highlighted the risks 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 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 also cautions 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 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 this 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. Essentially we want stakeholders today and 

the task force and all groups to be heard. We want people to underVerDate Mar 15 2010 03:42 Sep 19, 2012 Jkt 074856 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 E:\HR\OC\A856.XXX A856

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stand whatever recommendations are made and what the implications are from these recommendations. 

So I want to thank the witnesses that are here today for coming 

on relatively short notice. 

At this time I would recognize our ranking member, our temporary ranking member, I guess, the gentleman from Missouri, Mr. 

Blunt. 

OPENING STATEMENT OF HON. ROY BLUNT, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MISSOURI 

Mr. BLUNT. Well, I thank you, Mr. Chairman, and Mr. Deal will 

be here at some point during the hearing. I am 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. I think there will be large agreement from the 

committee and concern 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 recommendations 

routine mammograms for women between the ages of 40 and 49 yet 

this group accounts for about one out of six instances of breast cancer. I believe it is a huge mistake to send a message to women and 

their families and health care providers that an early alert system 

is not beneficial or may not be beneficial. As a cancer survivor myself, I am 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 have been talking about encouraging 

more prevention in the health care arena, these recommendations 

run counter to almost every other discussion that we are having. 

I am 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 board has recommended are not necessary. 

Mr. Chairman, I think this is an important hearing. I congratulate you for holding it. 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. 

Mr. PALLONE. Thank you, Mr. Blunt. 

Next is our chairman, Mr. Waxman, the gentleman from California. 

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Mr. WAXMAN. Thank you, Chairman Pallone, for holding this important hearing. 


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Today we are going to talk about an issue about which people 

have strong views: which women should be routinely screened for 

breast cancer and when. It is a question that 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 40. 

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 or NIH or any number of cancer-related research 

or advocacy groups. Just as we have seen with prostate cancer 

screening, immunization schedules and even last week cervical cancer screening as well as numerous other services, new information 

or new interpretations of old information often result in a change 

in what the experts tell us works at all or works most effectively 

at all, and this is how it is supposed to be. As the science of medicine evolves, so too should 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 2002 mammography guidelines: to take a fresh look at what has been learned 

over the last several years and based upon that body of work to 

provide its best 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 am also confidence that these recommendations are just that—recommendations, and that the task 

force would not expect them to be used to take the place of a 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 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 science 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 but to inform them. I hope that will 

be our sole focus here today. 

I look forward to hearing from all of our witnesses and thank 

them in advance for their testimony. Thank you, Mr. Chairman. 

[The prepared statement of Mr. Waxman follows:] 


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Mr. PALLONE. Thank you, Chairman Waxman. 

Next is the gentleman from Illinois, Mr. Shimkus. 

OPENING STATEMENT OF HON. JOHN SHIMKUS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS 

Mr. SHIMKUS. Thank you, Mr. Chairman, and I hate to disappoint Mr. Waxman but this will not be our sole focus today because this is the canary in the coalmine. This is what we get when 

we have government intervention starting to dictate health care 

policy decisions and this will not be taken outside the context of 

H.R. 3962, 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 in 

this country pretty soon, 2013, and definitely in 10 or 15 years. We 

will be able to point out in H.R. 3962 the ratings of A and B in 

the essential benefits package and the highest rating of C, women 

would not receive access to regular mammograms until the age of 

50. One estimate finds rationing of care like this would result in 

50,000 preventable deaths from women who go undiagnosed. H.R. 

3962 does give the Secretary the ability to add benefits but only 

after getting approval to do so from a new bureaucracy that is created called the Health Benefits Advisory Council. Will the new 

Health Benefits Advisory Committee take into account cost when 

making decisions? Will the committee make recommendations another government board like the task force has said shouldn’t be 

covered? When mammograms and other services aren’t covered by 

government, where will people turn? In Canada, we know those 

people can turn to the United States market. In the U.K., they are 

allowed to purchase their own private plan, this creating a twotiered system. 

Under H.R. 3962, 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 plan 

is to be offered in the exchange. These plans will cost more money 

and in 2013, 2014, anyone receiving subsidies to help them afford 

insurance can only purchase a basic plan. How 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 to ration care, and I yield back my 

time. 

Mr. PALLONE. The gentlewoman from California, Ms. Eshoo. 

OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Ms. ESHOO. Thank you, Mr. Chairman, for holding this very important hearing today. I want to welcome the witnesses, the members of the task force, the National Breast Cancer Coalition, the 

American Cancer Society and the Susan Komen Foundation here 

today as well, and to thank you all for your work. 


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I will place a full statement in the record, but there are a couple 

of points that I would like to make at this moment, and that is, 

number one, I 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, but 

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 communications 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 

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, 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 that, and I think 

that that really drives to the core of what we are 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 their complicated bodies have been 

left out of so many of those decisions and not covered by them and 

that is why we have engaged in a whole new debate and hopefully 

we will be successful with our efforts to remain 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 about the discussion and the debate that they 

brought forward, so thank you. 

Mr. PALLONE. I want to thank the gentlewoman. 

The gentleman from Texas, Mr. Burgess. 

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Dr. BURGESS. Thank you, Mr. Chairman. 

I agree with the gentlelady’s previous statement that the fight 

against cancer knows no ideological or partisan lines, and I am certain the doctors who will be testifying before us today would agree 

with that. Cancer is a disease that all Americans fear and one that 

is all too often very, very close to home. We have learned in this 

committee that cancer is a complex disease, still has no cure but 

efforts geared towards prevention, early detection and treatment 

have made significant gains. We start there because as we embark 

upon this hearing, we must remember not to embrace policies that 

would undo the successes that we have enjoyed. I agree, we should 


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not make this partisan but the 2,000-page gorilla in the room is the 

bill that this House passed 2 weeks ago, and if things were just to 

stay as they are now, then the task force recommendations would 

be just that, recommendations. Doctors would be free to accept 

them or reject them. But what we have written in 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 13,000 Texans are expected to be diagnosed with breast 

cancer this year, so we come to these new recommendations made 

by the United States Preventive Services Task Force and they have 

made some pretty dramatic statements regarding breast cancer 

screening. Now, the whole concept of not participating in a monthly 

self-exam, well, okay, maybe that is a good thing but I cannot tell 

you as a physician practicing obstetrics and gynecology for 25 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 OB/GYN 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 are all happy when the tests 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 had these task force recommendations come up 2 weeks 

ago and I went home to Texas, and on my desk waiting for me was 

a periodical called OB/GYN News, not necessarily a peer-reviewed 

scientific journal but articles of the day which are of interest to 

practicing OB/GYNs are discussed and they had a story that ironically was the day before the task force recommendation came out 

that said headline, breast cancer deaths higher without routine 

screening, and this was from a report given to the American Cancer Society out in San Francisco and a rather startling statistic 

that Dr. Katie reported to this group that 345 breast cancer deaths, 

which was nearly three-fourths of the total, were in women who 

were not regularly screened. Women who were regularly screened 

had 25 percent of the cancer deaths. Women who did not have regular screening, 75 percent of the cancer deaths. I think that is trying to tell us something and I think again the 2,000-page gorilla 

in the room is this new brave new world of health care which Congress is going to dictate how things are happening and the recommendations of the 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 they designate. 

So I thank you for having this hearing. I think it is extremely 

important. I think it is extremely timely. I look forward to the testimony of our witnesses. Dr. Brawley, always good to see you. And 

I will yield back the balance of my time. 

Mr. PALLONE. Thank you, Mr. Burgess. 

The gentlewoman from California, Ms. Capps. 


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OPENING STATEMENT OF HON. LOIS CAPPS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Mrs. CAPPS. Thank you, Chairman Pallone, for holding this hearing. 

I am so pleased that you and we all have responded quickly to 

the release of the task force’s recommendation because there has 

been a lot of confusion underscoring the value of having hearings 

like this in our House of Representatives. I have just returned, as 

we all have, from our Thanksgiving break and I was with my family, and in fact as an aside, received my own annual mammogram 

during that time. I can assure you that the message is out there 

but I am afraid it is not necessarily the accurate one. So I am looking forward to hearing in great detail today how the task force arrived at its conclusions and what the recommendations really mean 

in a practical sense. 

Unfortunately, there are people who have completely twisted 

what the task force is, what the task force does and what its recommendations mean. The scare tactics I have witnessed since the 

release of the recommendations have been deplorable, 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 owe it 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 

health care professionals. The task force’s website affirms 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 is information that clinicians should use to make 

decisions in consultation with their patients and nothing more. 

So 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 unanimous consent to 

enter a letter from the Partnership for Prevention into the record. 

The partnership is a group of reputable organizations, the American Academy of Family Physicians, Nurse Practitioners, Physicians Assistants and on and on, there is about 10 of them, and they 

are calling attention to our committee on the three most common 

misstatements that have appeared in the media, one being that 

that the task force recommends that women age 40 to 49 not receive mammograms, this is nowhere in the report, that the intention of the task force was to reduce cost, this is nowhere in their 

analysis, and that they are not qualified. These are some of the 

misstatements out in the public that this task force is not qualified 

to make recommendations or that they have other agendas in play, 


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and I ask that the letter be made part of the record, and I yield 

back. 

Mr. PALLONE. Without objection so ordered. Thank you, Ms. 

Capps. 

[The information follows:] 


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Mr. PALLONE. Next is the gentleman from Georgia, Mr. Gingrey. 

OPENING STATEMENT OF HON. PHIL GINGREY, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF GEORGIA 

Dr. GINGREY. Mr. Chairman, I thank you. 

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 are talking about Newton’s third law here, by the 

way. We are not talking about exact science. We are talking, I 

think, about an opinion, a judgment that is made by the United 

States Preventive Services Task Force, 15 or so members, based on 

looking at a lot of studies. I will tell you as a practicing OB/GYN 

physician, like my colleague from Texas, Dr. Burgess, I have spent 

26 years practicing medicine. In that specialty, I am a very proud 

member of the American College of Obstetrics and gynecology and 

a board-certified fellow, and we take our recommendations from 

that organization and from the standard of care in the community, 

my community, the greater Atlanta area, of what is best practices, 

and the American public and particularly the American women, 

they know who the American Cancer Society is. They know who 

the Susan G. Komen for the Cure organization is. So many of them 

help raise money for that organization but very few of them have 

ever heard of the United States Preventive Services Task Force or 

in what department they are embedded and how much power they 

have and how much authority they have, Mr. Chairman. They will 

find out pretty darn soon, and I would refer them to pages in both 

the House and the Senate bill, the Senate bill of course pending, 

the House bill 3962, and let them just connect the dots and to see 

the power that this organization, this U.S. Preventive Services 

Task Force, no matter what they call it, to tell physicians basically 

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 liability reform in 

these pending 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 guideline and not order a 

mammogram for our patients between the ages of 40 and 49 or not 

recommend it to them that they do breast self-examination, and we 

miss a 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 a lump was detected or a suspicious 

marking on the mammogram, the patient had a needle biopsy, it 

turned out to be benign, but unfortunately, she developed a breast 

abscess and then the physician gets sued for not following the recommendations and doing something that is, quote, unnecessary. So 

you put doctors in an untenable position and you put their patients 

at risk of death. 

So I can’t wait to hear from Susan G. Komen and from the American Cancer Society and obviously from the Preventive Services 

Task Force and the others on the panel. Mr. Chairman, with that, 

I will yield back. 

Mr. PALLONE. Thank you. 

The gentlewoman from the Virgin Islands, Ms. Christensen. 


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OPENING STATEMENT OF HON. DONNA M. CHRISTENSEN, A 

REPRESENTATIVE IN CONGRESS FROM THE VIRGIN ISLANDS 

Mrs. CHRISTENSEN. Thank you, Chairman Pallone. 

Given the confusion and the uncertainty the updated recommendations on screening for breast cancer by the U.S. Preventive Services Task Force has elicited, this hearing I hope will bring 

some clarity which I feel is needed on both sides, and I thank you 

for holding it. 

I have only read the executive summary but I have several questions like why now. Did the task force not foresee the reaction that 

has occurred, and why was it just released as an article as important as it is and now in a briefing with press and stakeholder organizations. As an African American woman who has had friends and 

family diagnosed in their 20s, their 30s and 40s, many with no 

known risk factors, some with good outcomes and others who died 

because of the aggressive of their disease, and as a physician who 

knows the pain of caring for women who came with very late stage 

carcinomas like the 24 black women who are going to be reported 

on shortly diagnosed in this city by Dr. Wayne Frederick, the head 

of the cancer center at Howard, in a recent 18-month period, 24. 

I am not pleased to say the least with the report not specifically 

addressing those of who die most often from this disease. 

Mammograms are not perfect and perhaps least so in the 40 to 

49 age group, but as part of the full armamentarium, it is the best 

we have today. We have never told women that mammograms are 

all that there is. As Dr. Frederick of Howard said, and Ms. Luray 

and Dr. Brawley will attest, 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 modalities, and while is most evident in the uninsured, copays create almost equal barriers to women with insurance, and neither 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. There is inadequate funding to 

meet the need. 

Until every woman has access, you can well imagine that we will 

not welcome, I will not welcome, anyway, these kinds of narrow 

recommendations. What is next? Colonoscopy screening for cancer 

screening? It probably saved my life, and not having one has 

caused me to lose too many friends. The task force is independent, 

which I consider a good thing. It is 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 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 offered had been accepted. They are similar to ones that we 

recommended for H.R. 3962. 

But I welcome all of the panelists today and I look forward to 

the testimony. 

Mr. PALLONE. I thank the gentlewoman. 

The gentleman from Pennsylvania, Mr. Pitts. 


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OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH 

OF PENNSYLVANIA 

Mr. PITTS. Thank you, Mr. Chairman, for convening this hearing. 

On November 16, 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 since caused widespread confusion and concern, primarily its 

recommendations for women age 40 to 49. The task force recommended against routine screening mammography in women age 

40 to 49 but did say that certain patients in this age range based 

on individual factors should be screened. This is a change from the 

task force’s 2002 recommendation that all women age 40 and older 

receive screening mammography every 1 to 2 years. 

The U.S. Preventive Services Task Force was first convened by 

the Public Health Service in 1984 and since 1998 it has been sponsored by the Agency for Health Care Research and Quality, a 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 19, Secretary Kathleen Sebelius said, 

‘‘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.’’ Basically she told 

women to ignore the task force recommendations. The good news 

for women age 40 to 49 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 the House-passed health reform bill, H.R. 

3962, becomes 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 Force on Clinical Preventive Services 

must be covered, but according to the task force’s just-released recommendations, routine mammograms for women age 40 to 49 received only a grade C. Should the health reform bill become 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 in the essential benefits package except to premium plus plans and then only if the added benefit is approved by the health benefits commission. So, for example, 

if the essential benefits package did not coverage routine mammograms for women age 40 to 49, insurance plans would be forbidden 


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from covering them. My State of Pennsylvania requires that all 

plans cover mammograms for women age 40 to 49. If this bill were 

to become law and the Secretary were to adopt these breast cancer 

screening recommendations as is as part of the 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 will come between 

patients and their doctors. 

I look forward to hearing our distinguished witnesses. Thank 

you, and I yield back my time. 

Mr. PALLONE. Thank you, Mr. Pitts. 

The gentlewoman from Florida, Ms. Castor. 

OPENING STATEMENT OF HON. KATHY CASTOR, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF FLORIDA 

Ms. CASTOR. Thank you, Mr. Chairman, very much for the hearing today because it not only gives us an opportunity to further understand the recommendations as to breast cancer screening but it 

affords us an opportunity to raise awareness about the real issue 

involving women’s health in America and that is access to care, 

plain and simple. 

For women in America, access to care, affordable health care, including screenings of all kinds, eclipses the debate over what age 

women and their doctors should begin routine mammograms. For 

millions of women across America, this debate has no application 

whatsoever. They are not receiving screenings at age 50, they are 

not receiving screenings at age 60. They simply do not have access 

to affordable health care because our health care system in this 

country is broken. 

It is 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 are simply not going to receive any screening 

whatsoever. Women in this country just do not have access to affordable care. Maybe one-quarter of women in the State of Florida 

that do not have health insurance will receive some mammogram 

during age 40 to 60, and it is much worse if you are African American or Latina. The disparities in screenings, diagnosis and treatment exist and I think this is the critical issue that Donna 

Christensen has raised that really deserves a great deal of attention and debate and it is the proper place for our outrage over 

women’s health in America because regardless of your insurance 

status, if you are African American, you are 1.9 times more likely 

to be diagnosed with an advanced stage of breast cancer than white 

women and Hispanic women are almost 1-1/2 times more likely to 

be diagnosed than white women. 

So the real concern here and the proper place for our outrage is 

access to care in and of itself. Our 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 


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in America that affects, yes, breast cancer screening but really is 

the heart of the problem in our fight to making America a healthier 

country. Thank you. 

Mr. PALLONE. I thank the gentlewoman. 

Next is the gentleman from Michigan, Mr. Rogers. 

OPENING STATEMENT OF HON. MIKE ROGERS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MICHIGAN 

Mr. ROGERS. Thank you, Mr. Chairman. 

You know, science is a whole 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 task force says that screening 1,339 women in their 50s to 

save one life makes screening worthwhile at that age yet the task 

force also says that screening 1,904 women ages 40 to 49 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 CBE is the opportunity cost incurred 

by clinicians and the patient encounter. Clearly, cost is a consideration. They did it with digital mammography. Digital mammography is more expensive than film mammography and talks about 

the cost-benefit analysis of that as they work their way through. 

Magnetic resonance imagine—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 is just not. 

It clearly was the reason, and to say, well, they don’t have any authority. Wait until 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 40 and 49. That is where we are going. 

As a matter of fact, in your 2,000-page bill, that is exactly what 

you do. The Health Benefit 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 23 to 25 for young women. Why? Why did they do 

it? Because science told them? No, to save money. And what the 

math part of your science equation is, we think that we are willing 

to accept that more women will be diagnosed later on in later 

stages of cancer. We are willing to accept a higher mortality rate 

to save money. That is what this report says and that is what we 

are getting ready to foist on the American people. That is not a 

scare tactic. That is 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 know Mr. 

Blunt is a cancer survivor because of early screening. Why we 

would foist this 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 are saying is, this 2,000-page 

bill and its 118 new boards, commissions and other government 

agencies that will dictate your health care policy is wrong and we 


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can and we should by these women in their 40s do much better, 

and I would yield back the remainder of my time, Mr. Chairman. 

Mr. PALLONE. Thank you, Mr. Rogers. 

Next is—I am having a hard time seeing who is here. The gentlewoman from Illinois, Ms. Schakowsky. 

OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS 

Ms. SCHAKOWSKY. Thank you, Mr. Chairman, for moving so 

quickly to convene a hearing on the recommendations of the U.S. 

Preventive Services Task Force. I appreciate it. 

This committee has talked a lot about the need for evidencebased 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 their ramifications for individual women. Many 

of my constituents have questions, as do I, and I look forward to 

asking them. But I do want to say right now that this is not something that should 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 ensure women, 

especially women threatened with life-threatening diseases like 

breast cancer and make sure that they have access to the health 

care that they need without preexisting-condition exclusions, gender rating denials that exist today. 

But among the questions that have been asked is, 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 are getting the research and 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 adequate insurance coverage or high cost sharing don’t prevent barriers to screening and all appropriate follow-up care? Women across the country 

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 am eager to hear from our witnesses and discuss the task 

force’s recommendation and again, Mr. Chairman, thank you for 

having this hearing. I yield back. 

Mr. PALLONE. Thank you. 

The gentleman from Arizona, Mr. Shadegg. 

OPENING STATEMENT OF HON. JOHN B. SHADEGG, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF ARIZONA 

Mr. SHADEGG. Thank you, Mr. Chairman, and I want to also 

thank you for holding this hearing so quickly on this important 

topic. I believe I have mentioned to this committee before that my 


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older sister is a 20-year breast cancer survivor so I have a keen interest in this topic. 

The breast cancer treatment guidelines released on November 

16th 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 have commented that these 

recommendations are merely guidelines for insurance companies 

and government officials trying to assess the relative value of 

mammography, clinical breast exams and breast self-exams. In a 

written statement, Health and Human Services Secretary Kathleen 

Sebelius 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 ‘‘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 every women in America that 

under this bill, H.R. 3962, which has already passed this Congress, 

that statement will not be true. Indeed, under this bill, the recommendation of this task force would become binding law, and if 

so, it would be devastating to access to mammograms and nothing 

short of catastrophic for women’s health in this country. 

In their recent report, mammograms for women age 40 to 49 

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. The panel also found insufficient evidence to determine it is worth screening over the age of 74. Again, 

because the grade was neither an A nor a B, it was an I, insufficient, under this bill those women could not get mammogram 

screening legally under any public plan. 

But it is important to understand precisely how far this bill goes. 

Because it does not just prohibit mammogram screening if this 

were the finding of this same task force after H.R. 3962 becomes 

law, it would prohibit private insurers, make it illegal for private 

insurers to provide mammogram coverage to women in these age 

groups. That is what the law says. Let me explain. Under the 

House bill, private insurers can offer four plans: one, a basic plan; 

two, an enhanced plan; three, a premium plan; and four, a premium plus plan. Under section 303 of H.R. 3962, 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 is 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 

mammograms were not given either an A or a B rating. 

With regard to the top category, premium plus, an insurance 

company could offer coverage for mammograms but if and only if 

the health choices 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 


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with it. Certainly having the government prohibit people who 

choose to be able to buy mammogram coverage is not what was intended by the authors of this legislation but in fact that is what 

the bill does. The government would prohibit millions of women 

from buying coverage for mammograms. The government would 

forbid private plans from offering mammogram coverage to millions 

of women. Poor and middle-class Americans by force of law would 

be prohibited from getting mammogram coverage under the insurance exchange—— 

Mr. PALLONE. The gentleman is 2 minutes over. 

Mr. SHADEGG [continuing]. Created in this bill. 

I thank the gentleman for his indulgence and hadn’t realized I 

had gone over time. Thank you. 

Mr. PALLONE. Thank you. 

The gentleman from Maryland, Mr. Sarbanes. 

OPENING STATEMENT OF HON. JOHN P. SARBANES, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MARYLAND 

Mr. SARBANES. Thank you very much, Mr. Chairman, for holding 

this hearing. I expect we are going to hear a lot about rationing 

today from the other side. To me, the discussion today isn’t about 

rationing, it is about being rational in looking at all of the evidence 

that is available to us and making smart decisions about what kind 

of treatment we should deploy and what kind of coverage there 

should be, and I think the jury is out on this. That is why we are 

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 mind. 

I am glad we are 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 is 

a good thing. Now, there may be other considerations at play here. 

One of them is clearly the high attention that there is to mammography screening and the education effort that has gone 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 HHS will be considering all of those things going forward. But to put our head in 

the sand and not look at the science, it seems to me would be a 

serious mistake. So we ought to review these recommendations 

with a sober and dispassionate consideration. I think that is what 

we are called upon to do. I would assume that that is what the 

Health Benefits Advisory Committee would do in receiving recommendations from any other government body. The notion that 

one—we have 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 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 think that this is a good conversation to be having and I 

thank the commission for putting the recommendations forward, 


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for basing them on science, and now we are going to have to consider those in the light of many, many factors in judging how to 

move forward. So I look forward to the testimony of the witnesses 

and I yield back my time. Thank you. 

Mr. PALLONE. I thank the gentleman. 

The gentlewoman from Tennessee, Ms. Blackburn. 

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF TENNESSEE 

Mrs. 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 I will submit for the record, but I do 

want to make a few comments as we begin 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. We 

are concerned about what you all as the task force brought forward. Sure, we are 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. 3962 were to be passed and read into law. You all have a 

portfolio of 105 topics. That gets to the heart of the issue because 

when you start reading on H.R. 3962 on page 1,296 in Title 3 and 

you look at section 2301 of this bill, the decisions you make do end 

up having the weight of the law placed behind them, and when you 

read specifically on pages 1,317 and 1,318, 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 bill then and read it and read that 

title. Look at section 3101. Look at section 2301. Go back and look 

on pages 110 to 112 at how what you do and how you give priority 

and preference to certain treatments and certain categories is going 

to carry the weight of law. 

Now, it is concern to me when I hear statements made by Members of Congress that we are going to deploy certain treatments or 

certain health care. That ability should rest with the patient and 

their physician. We do not need a bureaucrat in that exam room. 

And yes, indeed, when you read this bill, we do have concerns that 

it will lead to rationing because the decisions appear that they are 

being made on cost and not on health care. 

So I welcome you all. I appreciate your time. We are going to 

have a lengthy number of questions. And Mr. Chairman, I yield the 

balance of my time. 

Mr. PALLONE. I thank the gentlewoman. 

Chairman Dingell, the gentleman from Michigan. 

OPENING STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MICHIGAN 

Mr. DINGELL. I flew back this morning from Michigan hoping to 

have a rather informed hearing on a very important point. I find 

that I have come back to listen to some fairy tales coming from the 


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other side of the aisle and I find myself offended by the lack of attention that my Republican colleagues have given to the health bill 

and I find myself very much offended to listen to the kind of distorted logic and reasoning with which I am being afflicted as I 

enter this room. I have great affection and respect for my friends 

on the other side of the aisle and I am willing to assume that their 

behavior this morning in making the comments I am hearing about 

these recommendations and how they will play with the bill is bottomed on a lack of attention, study, knowledge or diligence in understanding either the bill or the recommendations of the U.S. Preventive Services Task Force. 

It has been a little bit like listening to the fairy tales of the 

Brothers Grimm, but to set the record straight, I want my colleagues to understand the bill does not in its provisions 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 have heard from that side of the 

aisle always with great personal offense. They talked about how we 

are going to pull the plug on Grandma, how we are going to push 

euthanasia forward, how we are going to deny health care to deserving people because of this legislation. These recommendations 

that we are going into this morning are recommendations, nothing 

more, and to say anything different than that is either to transmit 

the grossest kind of carelessness or, and I hope this is not the case, 

just plain outright deceit. 

It is time for us to look at these recommendations are they are: 

the recommendations of a scientific panel created to make advice 

on what is the best medical practice and how we can see to it that 

we best protect our women with regard to things like Pap smears 

and mammograms. 

Now, I will yield to no one on either subject because this committee and the Oversight Subcommittee when I was chairman of 

each were responsible for seeing to it that both mammograms and 

Pap smears were made in the safest way for the benefit of patients. 

I lost my mother to cervical cancer and I lost lots of friends to 

breast cancer and other things, and I am grossly affronted by the 

statements that I have heard coming from the other side in which 

they tell us how these recommendations and the health bill on 

which we are working so hard are going to deny women mammograms, proper mammography and Pap smear and other needed 

services. That is offensive. It is just plain wrong. It is absolutely 

false. And I would urge my friends on the other side to 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 fears and faults which 

do not exist. I am affronted, Mr. Chairman, and I hope that this 

record and this hearing will correct some of the unfortunate misapprehensions and misstatements that have been flowing thickly 


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from the other side of the aisle this morning. I ask unanimous consent to revise and extend my remarks. 

[The prepared statement of Mr. Dingell follows:] 


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Mr. PALLONE. So ordered. Thank you, Mr. Chairman. 

Our ranking member, the gentleman from Texas, Mr. Barton. 

OPENING STATEMENT OF HON. JOE BARTON, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BARTON. Thank you, Chairman Pallone, for holding this 

hearing. 

I listened with great affection and with great interest to my good 

friend from Michigan, former Chairman and current Chairman 

Emeritus Dingell’s opening statement. I think it goes without saying the personal esteem and professional respect that I have for 

him. Having said that, there are no fairy tales being told on this 

side of the aisle this morning. Here is the bill that passed the 

House. In this bill on page 1,762, the U.S. Preventive Services Task 

Force is given the authority, and I quote ‘‘to determine the frequency, the population to be served and the procedure or technology to be used for breast cancer screenings covered under the 

Indian Health Service.’’ Section 303 of the legislation states, and I 

quote, ‘‘The commissioner shall specify the benefits to be made 

available under the exchange participating health plans.’’ In plain 

English, Mr. Chairman, what this means is, the new health choices 

commissioner will determine what preventive services including 

mammography are covered under the health insurance that is in 

this bill. 

Now, we also know that the U.S. Preventive Services Task Force 

is an outside independent counsel of doctors and scientists who 

make recommendations. They do not set federal policy and they 

don’t determine what services are to be covered by the bill but 

their recommendations are going to be seriously listened to. 

Now, I have an aunt who passed away in her early 50s as a consequence of breast cancer. I have a sister who was diagnosed with 

breast cancer in her 30s, luckily received proper treatment, had a 

mastectomy and so far in the last 10 years is cancer-free. I have 

a wife, beautiful wife who is under the age of 50 and she has annual mammograms every year. I have a good friend who was just 

diagnosed with breast cancer who is in her mid 40s. Again, she’s 

undergoing treatment. Hopefully she is going to have a good outcome. 

To have a task force make the recommendation that has been 

made and to have in this bill the authority that is given to various 

unelected bureaucrats to make health care decisions including coverage and frequency in my opinion is wrong. Now, on a bipartisan 

basis, this subcommittee and the full committee repeatedly has 

passed bills increasing and supporting the early detection of breast 

cancer, the prevention, the research. I mean, we do it almost every 

Congress. So we are 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, it is waiting 

approval in the Senate. This is an excellent time to hold this hearing. I appreciate the subcommittee chairman and the full chairman’s personal attendance, but let us don’t talk about fairy tales. 

Let us talk about the facts, the plain English of these bills. And 

if we continue to agree rhetorically, then we need to begin to make 

substantive changes in the legislation to prevent what we all say 


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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 women or for that matter more mature women 

over the age of 74 developing breast cancer because they are not 

allowed a mammogram. My good friend to my right, Mr. Rogers of 

Michigan, had an amendment that was passed at 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 disappeared. 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 us not talk about fairy 

tales when we can read these bills. Now, I am not saying the bill 

is a fairy tale but I will say the bill is not reflective of the policy 

that members on both sides of the aisle say they support. 

With that, Mr. Chairman, I yield back. 

[The prepared statement of Mr. Barton follows:] 


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Mr. PALLONE. Thank you. 

Next is the gentleman from Texas, Mr. Green. 

OPENING STATEMENT OF HON. GENE GREEN, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. GREEN. Thank you, Mr. Chairman, and I appreciate the opportunity you have in so quickly dealing with this. 

First of all, I want to thank the chairman emeritus for his offer, 

Chairman Dingell willing to conduct a class on remedial health 

care comprehension, and my only question is, 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 will 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 

40-year survivor of breast cancer and she so fit the exception, and 

it took me as a Member of Congress—I can’t practice law, but believe me, I will file suit against our carrier if they continue not 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, it all rests on our shoulders and I think 

that decision ought to be made by elected officials. 

Now, this group will take recommendations from everyone but 

ultimately it is going to be our decision and we will continue to provide legislation to have minimum benefits, and the statement I 

have, in 2002 the task force changed their breast cancer screening 

to a grade B to recommend mammograms every 1 to 2 years for 

women 40 to 75. That was only 7 years ago. And yet now the task 

force is making a change. Two weeks ago they revised it and made 

a grade C, and that’s the issue I think that my colleagues are talking about, that women at the age of 40 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 in fact doctors on both sides. I 

have doctors tell me all the time that they have battles with insurance companies saying we need to do this and the insurance company won’t allow it, and they are the ones that are practicing medicine and that is a battle that has to be fought every day no matter 

what happens if we pass a national health care bill. But to use this 

opportunity to pick at the national health care bill I think is interesting because the task force will be given the opportunity to clarify their statements and I am glad we have the testimony here 

today. 

The adverse reactions to the poor wording of the task force recommendations obviously have not gone unnoticed by our committee 

and the members of the committee. In fact, I have been contacted 

by a number of constituents in my district including M.D. Anderson 

Cancer Center in Houston about the recommendations. They were 

very public. They are opposed to the task force recommendations. 

They will continue to recommend it 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 beginning at the age of 40 but these new screening recommendations 

will cause some access problems for women. 


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The topic is also especially sensitive because the reform bill 3962 

states that the U.S. Preventive Services Task Force recommendations A and B are mandated benefits and the bill also includes report language saying A and B recommendations are a floor for benefits, not a ceiling. The A and B are a floor. So the task force recommendation will be considered that but the decision could be 

made still no matter what the task force says. So that is what we 

are here today to talk about. I have concerns about jeopardizing access to preventive screenings for women, especially since I represent a majority Latino district that is medically underserved, and 

I worked for years in Congress to expand the coverage of mammograms in our community for primary and preventive care services. 

I like the fact that the task force is an independent commission 

and is designed to keep politics out of medical recommendations because I can be an expert for 30 seconds on anything but I do depend on the experts to be able to make those decisions. 

Again, I look forward to the testimony, Mr. Chairman, and I ask 

unanimous consent that my full statement be placed into the 

record. 

[The information was unavailable at the time of printing.] 

Mr. PALLONE. Without objection, so ordered. Thank you, Mr. 

Green. 

Next is the gentlewoman from North Carolina, Ms. Myrick. 

OPENING STATEMENT OF HON. SUE WILKINS MYRICK, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NORTH 

CAROLINA 

Mrs. MYRICK. Thank you, Mr. Chairman. Thank you for holding 

the hearing today. 

I understand that 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 the preventive side because to me it is sending the 

wrong message to women. It is saying you don’t have to be vigilant, 

you don’t have to take care of yourself, you don’ have to do preventive care, and the reason that concerns me is, I am a 10-year breast 

cancer survivor. I am one of those who persevered literally to find, 

you know, my own cancer because I knew something was wrong 

with my body and I had good doctors who helped me. But because 

of that, I am here today, and we all know that earlier detection 

means longer survival. I mean, that is a no brainer. So many 

women really say to me I don’t want to get a mammogram, it 

hurts, 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 

point whole in this is, you know, you better find out sooner rather 

than later because of what I said before. 

So I am very concerned 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 self-exams, and especially, you know, younger women today. There are so many younger women in my area 

that are in their 20s and 30s getting breast cancer, they have their 

own support group and that never used to happen. So when we 


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talk about what we need to do, I hope that we will very seriously 

consider, you know—and I am glad the panel is going to be here 

to explain why they did what they did. But 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, 

especially with younger women. 

So, Mr. Chairman, I appreciate this opportunity very much and 

just look forward to hearing the recommendations from the panel. 

Mr. PALLONE. Thank you. 

The gentlewoman from Wisconsin, Ms. Baldwin. 

OPENING STATEMENT OF HON. TAMMY BALDWIN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF WISCONSIN 

Ms. BALDWIN. Thank you, Mr. Chairman. I appreciate your calling this hearing of the Health Subcommittee to discuss what is 

both a deeply personal and deeply political issue for myself and as 

you have heard many of our colleagues in this room. 

The U.S. Preventive Services Task Force was authorized by Congress to deliver recommendations regarding the efficacy of clinical 

preventive services. Ideally, these recommendations will be used to 

inform primary medical care. On November 16, 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 40, 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 preventive 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 issue 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 


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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. 

Mr. PALLONE. Thank you. 

The gentlewoman from Colorado, Ms. DeGette. 

OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO 

Ms. DEGETTE. Thank you very much, Mr. Chairman. I will submit my full statement for the record. 

I just want to say that as Mr. Sarbanes said, we have got to look 

at science here and we have got to look at the recommendations 

based on science which, you know, sometimes I feel revolutionary 

in Congress saying that, but that is what we need to look at. All 

of this excitement on the other side of the aisle about how these 

recommendations are going to be implemented, first of all, Mr. 

Green said, it is not a ceiling, it is just a floor, but secondly, even 

if they were implemented, most of them probably we wouldn’t object to. The recommendations say, number one, the decision to initiate regular screening mammography in women age 40 to 49 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, biannual screening mammography for women age 50 to 74 years. Number three, 

insufficient evidence to assess the additional benefits and harms of 

screening in women over 75 years or old, and then the others. 

So really, if you actually look at the recommendations, they probably do make some sense from a scientific standpoint but I have 

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. 

It is not a one-size-fits-all testing. That makes sense to me. But if 

you look at the 24-hour news cycle, that is not what is being said 

to people. They are scared, they are confused. And when you add 

the misinformation that we hear from some of my friends on the 

other side, they are triply confused and scared because they think 

now when we have a health care plan that applies to everybody, 

suddenly they are going to be told that they can’t have tests that 

they need, and that is simply not the case. 

So, Mr. Chairman, that is why I came down and sat through all 

the opening statements and am 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 is it that women need to be talking to their physicians about. Ultimately it is going to be the decision of the physician and the woman what they need and they need to figure that 


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out and then they need to feel secure that they are getting the level 

of testing that they need. Thank you, Mr. Chairman. 

Mr. PALLONE. I thank the gentlewoman. 

Next is the gentleman from Ohio, Mr. Space. 

OPENING STATEMENT OF HON. ZACHARY T. SPACE, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF OHIO 

Mr. SPACE. Thank you, Mr. Chairman, for taking the time to 

hold the hearing on this very important issue. 

Cancer is a terrifying specter for all Americans and almost all of 

us have had a loved one or a friend who has 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 Congresswoman Myrick’s comments, and I find them very consistent with those just provided by 

my colleague from Colorado, Congresswoman DeGette. But we have 

heard some things from the other side of the aisle today that I 

think cause us or certainly cause me considerable concern. I think 

that it is 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. You know, I think it is 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 is disingenuous to on 

the one hand defend the status quo which sees the insurance industry every day making decisions about the lives of their insureds 

based on strictly financial considerations and then on the other 

hand condemn a system because you speculate that these kinds of 

recommendations will lead to the rationing of care. 

Second, what this bill does do is, it provides the benefit of insurance to millions of Americans that don’t have it and then following 

on what Dr. Christensen mentioned earlier, it is not just those 

Americans that don’t have insurance that would benefit from this 

bill when it comes to preventive care and access to mammograms, 

it is those who have insurance but can’t afford the copayments, 

specifically those who are indigent or middle-class Americans. That 

makes a difference for them. This bill makes preventive care a 

basic and fundamental right for every American. That means again 

that my constituents, the 65,000 of them that have no access to 

coverage right now and tens of thousands more who can’t afford 

copays will now have access to things like mammograms when they 

wouldn’t have otherwise had that. 

These are questions that we all should be asking: what is the net 

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ing these rational questions, again as my colleague from Maryland 

indicates, based on reason and science. 

With that, Mr. Chairman, I thank you once again for calling this 

hearing and yield back. 

Mr. PALLONE. Thank you. 

The gentlewoman from Ohio, Ms. Sutton. 

OPENING STATEMENT OF HON. BETTY SUTTON, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF OHIO 

Ms. SUTTON. Thank you, Mr. Chairman, for holding this extremely important hearing on the recommendations from the U.S. 

Preventive Services Task Force on mammograms for women in 

their 40s. 

As we have all heard and has been discussed here, the task force 

is no longer recommending routine mammograms for women in 

their 40s, 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 is the leading cause of death for 

women between ages 20 and 59. We all know people who have been 

touched by breast cancer, people that we love 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 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 2007, only 70 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 are 40 or they are 60, are not screened is 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 preventive care. 

So let us be clear, that providing access to health insurance 

means providing access to preventive care which means saving 

lives. So what is 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 it certainly should not discussions otherwise representations otherwise should not be used as we debate and discuss this 

very important issue to derail 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. 

Mr. PALLONE. Thank you. 

The gentleman from Iowa, Mr. Braley. 


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OPENING STATEMENT OF HON. BRUCE L. BRALEY, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF IOWA 

Mr. BRALEY. 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-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 and 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. I will 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 is what is wrong with our broken health care delivery 

system and that is why comparative effectiveness research is such 

a critical part of a rational discussion about health care policymaking. 

In an earlier hearing in this same subcommittee, I talked about 

a hearing that took place in this very room years ago when a researcher advocating high-does chemotherapy with bone marrow 

transplant for metastatic 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 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 health care bill be implemented in people dealing with health care issues. I think that in 

its position 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. Well, I agree with that, and all you have to look at is 

the next two sentences to find out why. This is what two of the sentences say, ‘‘The we said is that screening starting at age 40 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 


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have a mammogram for women in their 40s 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 are having is a healthy debate and 

what the most effective use and treatment for breast cancer patients is and that is what we need to focus on going forward, and 

I yield back my time. 

Mr. PALLONE. I thank the gentleman. 

Next is the gentleman from Utah, Mr. Matheson. 

Mr. MATHESON. Thank you, Mr. Chairman. I will be brief because I am looking forward to hearing from our two panels on this 

topic. 

In my State of Utah, the incidence of breast cancer is lower than 

most States, however, our mortality rate is high because women in 

Utah are diagnosed in cancer’s later stages. As a witness on our 

panel notes in his testimony, the recent recommendations provided 

by the U.S. Preventive Services Task Force November 16th have 

sparked concern and disagreement among providers, patients, families as well as sparked a public discourse that has led to further 

confusion and anxiety. 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 and treatment 

discussion is an individual one between a provider and a patient. 

So I hope today’s hearing can provide concrete information on the 

evidence-based decision-making processes of the task force but I am 

also interested to hear from the cancer community and medical 

providers on their next steps for outreach and patient education on 

the benefits and limitations of mammography screening. 

Thank you, Mr. Chairman. I yield back my time. 

Mr. PALLONE. Thank you. 

I believe that concludes the opening statements by members of 

the subcommittee, so we will now turn to our witnesses, and if our 

first panel would come forward, I would appreciate it. Thank you. 

We have two witnesses both from the U.S. Preventive Services 

Task Force. To my left is Dr. Ned Calonge, who is chair of the U.S. 

Preventive Services Task Force, and next to him is Dr. Diana 

Petitti, who is vice chair of the U.S. Preventive Services Task 

Force. Now, I will just mention as I think you know that we have 

5-minute opening statements from you. They become part of the 

record, and each of you may in the discretion of the committee submit additional statements in writing for inclusion in the record, 

and I would now recognize first Dr. Calonge. 

STATEMENTS OF NED CALONGE, M.D., M.P.H., CHAIR, U.S. PREVENTIVE SERVICES TASK FORCE; AND DIANA B. PETITTI, 

M.D., M.P.H., VICE CHAIR, U.S. PREVENTIVE SERVICES TASK 

FORCE 

STATEMENT OF NED CALONGE 

Dr. CALONGE. Good morning, Mr. Chairman and distinguished 

members of the committee. On behalf of our fellow task force memVerDate Mar 15 2010 03:42 Sep 19, 2012 Jkt 074856 PO 00000 Frm 00049 Fmt 6633 Sfmt 6633 E:\HR\OC\A856.XXX A856

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bers, we thank you for the opportunity to discuss the task force and 

our work. 

Our recently published recommendations on breast cancer 

screening have drawn a remarkable amount of attention. We recognize the communication of what the recommendations say was poor 

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 task force fully understand, most through personal experience, the impact of breast cancer on the lives of women and their families. Our job, though, is 

to rigorously review scientific evidence. Politics play no part in our 

processes. 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 both the publication schedule of the medical research journal 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 clinical preventive services and developing evidencebased recommendations for the health care community. Our primary audience for recommendations remains primary care clinicians. The task force has 16 volunteer termed members representing a diverse array of expertise in primary care and preventive health-related disciplines including adult, child preventive and 

behavioral medicine, women’s health, nursing and research methods. The AHRQ director appoints members from the chair’s recommendations developed from a public nomination process. Given 

the scope of topics covered, subspecialists who consult on or care 

for those identified through 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 105 clinical preventive services that are listed on our website. We strive to update 

topics every 5 years, which is what prompted the new breast cancer 

recommendations. To address a 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 report is created with 

working group consultation. Based on the evidence review and explicit methodology, the work group drafts a recommendation statement and at an in-person meeting the evidence and the draft statement are presented and discussed and the task force votes on the 

recommendation. 

There is careful attention to conflicts of interest such that members with potential conflicts are recused from discussion and vote 

or otherwise restricted in participation. Representatives of 24 partner organizations including all primary care specialties, key 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 


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expert consults from the relevant disease area such as oncologists 

and by other stakeholders such as 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 products. 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 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 A and B recommendations, they are sufficient net health 

benefits such as that primary care clinicians are recommended to 

provide these services for all appropriate patients. If there is no net 

benefit or there is net harm, we assign a D recommendation indicating to not provide the service. If gaps in the evidence prevent 

net benefit from being determined, we assign an I statement reflecting insufficient evidence, indicating that more research is needed. 

Finally, a C 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 being tested. The specific C language that we recommend against routine 

provision was intended for consideration by primary care clinicians, 

but unfortunately as played out in unintended ways in the public 

interpretation of the breast cancer recommendation. 

Congress through Public Law section 915 mandates that AHRQ 

convene the task force to address our mission. The role of AHRQ 

in the process is to support our activities and processes of AHRQ 

staff and the director of AHRQ do not vote or otherwise influence 

our decisions. 

I will have to admit to the committee that breast cancer is 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 Dr. Petitti to 

testify specifically about the breast cancer screening recommendation. 

[The prepared statement of Drs. Calonge and Petitti follows:] 


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Mr. PALLONE. I am sorry. I just wanted to thank Dr. Calonge and 

now ask Dr. Petitti to begin. 

STATEMENT OF DIANE B. PETITTI 

Dr. PETITTI. I am Diana Petitti. I am the vice chair of the U.S. 

Preventive Services Task Force. I am a physician and an epidemiologist. I have spent my entire 32-year career as a scientist 

working on issues of women’s health. I published on the topic of 

mammography screening. I served as vice chair of the National 

Cancer Policy Board and I have expert in evidence synthesis, systematic review and med 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 

weighing of the evidence that led to these recommendations. In 

specific, the task force recommends the following: women age 50 

through 74 should have mammography every other year. The decision to start regular, biannual screening mammography before the 

age of 50 should be an individual one and take the 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 40 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 40. The 

task force supports those decisions. 

The task force acknowledges that the language used to describe 

its C grade recommendation about breast cancer screening for 

women 40 to 49 did not say what the task force meant to say. The 

task force communication was poor. The task force is committed, 

really committed to improving its communication. 

The task force first addressed the screening mammography topic 

in 1989. At that time the task force recommended screening women 

50 through 75 every 1 to 2 years. With regard to screening younger 

women, the task force stated it may be prudent to begin screening 

at an earlier age for women at high risk of breast cancer. In its 

1996 guide, the task force recommendation was in favor of screening women 50 to 59 every 1 to 2 years. Mammography screening 

for women 40 to 49 was given a C grade. At that time the C grade 

recommendation meant insufficient evidence. In 2002, the task 

force recommended screening women 40 to 69 every 1 to 2 years, 

stating that the benefits were smaller and took longer to emerge 

for women who were first screened in their 50s. 

On November 16th, as this committee knows, the task force 

issued its updated recommendations on breast cancer services. I 

wish for us to clarify that the timing of issuance of these recommendations. In late 2006, discussion of a plan for updating recommendations began. The breast cancer topic came up for review 

at the regularly scheduled time. Work on the topic started in 2007. 

When the recommendation statements came up for a vote in November 2007, the members could not come to agreement about 

what to recommend because agreement about what to say about 

the balance of benefits and harms. In this context, the task force 


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asked for additional evidence from its evidence-based practice center. The task force considered this evidence at its July 14-15 meeting. 

In making its final recommendation, the task force considered 

evidence 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 and conducted by the cancer intervention and surveillance modeling network. The systematic review identified almost 

3,000 studies, and 550 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 40 to 64 has a benefit in reducing death due 

to breast cancer. The benefit is larger in older women than in 

younger women, and I would like to speak specifically to the issue 

of harms in this net benefit equation. 

Preventive services are provided to asymptomatic individuals for 

the sole purpose of preventing or delaying morbidity, delaying functional decline or postponing death. The promise of service delivery 

is net benefit, benefit minus harms. The benefits of mammography 

have been easy to communicate. The harms and potential harms 

have been difficult to communicate. The easily identifiable and 

commonly used definition of harm is physical injury. These physical injury direct harms are very, very small but the task force considers the harms of a screening test not just physical harms but 

psychological harms. 

A great deal of the controversy has centered on the task force use 

of consideration of anxiety and psychological distress as a harm of 

a false positive test. In particular, the psychological distress has 

been ridiculed. To understand the consequences of false positive 

tests, 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 how hard the concept of screening is explained, a positive mammogram screening test means cancer until 

cancer is proven not to exist. For some women who have a positive 

test, 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 test, a trip to a surgeon over a period of time that 

is not always short and over a period of time it is unpredictable 

and not within the control of the woman. Some women eventually 

need a biopsy. Cancer is a terrifying prospect. It carries special 

emotional weight because of the consequences of the diagnosis have 

in the past involve not only death but the prospect of mutilating 

surgery. Anxiety and psychological distress in women who have 

had positive screening tests is amply documented in the evidence. 

The task force wants only that screening mammograms be done 

with full knowledge of these potential harms, the frequencies of 

these harms and what is to be gained by being screened at an earlier compared with a later age. False positive tests are more frequent in younger than in older women. 

Other harms of mammography include ones that are less well 

documented. Some women are diagnosed in their 40s with cancer 


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that could have been treated just as well if diagnosed later. These 

women may have unnecessarily been exposed to the harms of treatment including surgery, chemotherapy—— 

Mr. PALLONE. Doctor, I didn’t want to stop because it is so important, but you are 2 minutes over, so keep going but—— 

Dr. PETITTI. I am going to say that—my final statement. Mammography starting at 40 should not be automatic. The task force 

recommends that women in their 40s decide on an age to begin 

screening that is based on a conversation with their doctor and is 

individual, and I apologize for going over. 

Mr. PALLONE. I am going to apologize for trying to stop you because it is so important that you clarify a lot of these things, and 

I appreciate that. 

Our procedure now is that we have questions from the members 

of the panel—I mean from the Members of Congress, and I will 

start with myself. 

Let me say that you have actually clarified some of the questions 

I was going to ask 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 ask you some questions as well. There 

are 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 recommendations, 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 different task force that is in the legislation, the larger health care reform legislation that we passed. In 

other words, you are the U.S. Preventive Services Task Force. The 

new task force in the bill that we pass has a different name, Clinical Preventive Services, but the A, B and the C ratings are the 

same or similar. 

But right now these A, B and C ratings have no force. They are 

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, they don’t have to cover anything, and in fact what we are getting is that a lot of insurance companies right now 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 screenings. 

So the point I am trying to make is that the big advantage of 

the health care reform bill that we pass is that H.R. 3962 will for 

the first time create minimum standards for requiring preventive 

benefits. 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 

is not now. The other thing that we do in the bill is that we say 

that the Secretary could require a C rating also be covered under 

both a public option or private insurance plans. In fact, my understanding is that the new task force—I mean the Secretary under 

the bill could even require a C rating under the basic benefit packVerDate Mar 15 2010 03:42 Sep 19, 2012 Jkt 074856 PO 00000 Frm 00068 Fmt 6633 Sfmt 6633 E:\HR\OC\A856.XXX A856

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age. Now, that is contrary to what some of my colleagues have been 

saying on the other side of the aisle, and my whole point here is 

to say that the truth is that if enacted into law, H.R. 3962 would 

result in a lot of people who are not getting mammograms, Pap 

smears, colonoscopies, 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 C either in the public option or in the private plan 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 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 under the Republican bill. Essentially it would just like the 

status quo that we have now. So I listen to the debate that we have 

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 would the Republican alternative that we have 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 is a C, there is some net benefit and the Secretary could decide under the new bill to say okay, that is going 

to be required as well. So you are not in any way with the C recommendation saying that this screening is not a good thing. In 

fact, you are actually saying there is a net benefit but you would 

like individual women to make that decision with their doctor because it is only a small net benefit. Is that accurate? 

Dr. PETITTI. Mr. Chairman, I am going to speak to the science. 

Mr. PALLONE. Absolutely. 

Dr. PETITTI. And the science is that a C recommendation does 

mean a small net benefit, and we map that C recommendation 

through advice that women make the decision with their doctors 

about whether or not to undergo screening. I think this committee 

is dealing with incredibly complicated issues about health reform 

and coverage but the task force is not a coverage and health care 

reform and policy committee; we are scientists. 

Mr. PALLONE. But the bottom line is—and I will end with this— 

is that even when you recommend a C you are saying there is a 

small net benefit, so again, let us not talk about today but let us 

talk about if the bill that we passed in this committee becomes law. 

Even then, you know, the Secretary could say okay, there is 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 to decide the way they do today. But, you know, the misinformation out there I think is that even under the bill that we 

passed, for once there is going to be a requirement that some of 

these screenings occur. If you rate it as an A, it has to be done. 

If you rate it as a B, it has to be done. If you rate it as a C, the 

Secretary can say it has to be done. Right now there is nothing, 


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nothing at all, and the Republicans in their alternative would continue the status quo that says you don’t have to cover anything, 

and I just appreciate it because I think you have helped me clarify. 

I yield now to the gentleman from Illinois, Mr. Shimkus. 

Mr. SHIMKUS. Thank you, Mr. Chairman, 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 is what we really 

need to do and that is what we are doing today, and we are using 

obviously what happened through your process to make the claim, 

the short-term concern of a public option, which many of my colleagues on the other side have said is the 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 rationed care. 

Now, the process, the scientific process that you have just admitted to said there is a small net benefit. When there is decreased 

revenue available, the default will be based upon 3962 just what 

you say on your website. Your website recommends against routine 

screening mammography in women age 40 to 49. Do you think that 

this statement would be perceived by women younger than 50 that 

they should not get a mammogram on your website? 

Dr. PETITTI. We have communicated very poorly about the C recommendation. It is clear that many women, many physicians and 

certainly the media interpreted that language as if we were recommending against women in their 40s ever having a mammogram. 

That was not our intention. 

Mr. SHIMKUS. I understand, but we are concerned of commissions. We are concerned of bureaucracy. We are concerned of rationed care. We are concerned about bureaucrats saying there is no 

real net benefit, and then—yeah, it is right. It is exactly what we 

are concerned about and that is why we are having this debate. In 

the bill, and Chairman Pallone pretty adequately talked about the 

differences—we know that services with a rating of A and B must 

be included in essential benefit package. In this case with the highest rating of C, women would not receive—currently if this was 

law, as is today, women in the C category would not receive this 

as a covered benefit under 3962, and that is part of our concern 

and this does segue into the full health care debate. The commissioner on part of the bill, and I don’t have the whole 2,000 pages, 

I just pulled out excerpts. The commissioner shall specify the benefits to be made available under exchange participating health benefits plans during each year, and then you can go further on. Basic, 

enhanced and premium, and then the premium plus, A, approved 

by the commissioner, and then you can go to the C section, which 

is again highlighted, and we continue to have preventive services 

including those services recommended with a grade A or B by the 

task force on clinical preventive services. 

So this is again for a lot of us an important debate. Do any of 

you know an individual who has been diagnosed for cancer between 

the ages of 40 and 49 personally? 

Dr. PETITTI. Oh, I know many individuals who have been diagnosed with cancer—— 

Mr. SHIMKUS. Dr. Calonge? 

Dr. PETITTI [continuing]. Between the ages of 40 and 49. 


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Dr. CALONGE. Yes. 

Mr. SHIMKUS. And then the other question, what about over the 

age of 74? Anyone who has been diagnosed with—— 

Dr. PETITTI. Yes. 

Mr. SHIMKUS. Because although we are focusing on 40 to 49, in 

your report over 74 has the I category, and we don’t even know if 

it is. So what are we saying to those over the age of 74? 

Dr. PETITTI. I speak to the evidence and to the mapping of the 

evidence to the task force recommendations. 

Mr. SHIMKUS. And I appreciate that, and I only got 38 seconds 

and I am going to be punctual on my time. Part of this concern 

with H.R. 3962 is as we said, the public option, the gateway to a 

one-payer system, eventually rationed care, and then a decision 

based upon the financial ability of the country to fund care across 

the spectrum but also our seniors in our country, and again, this 

incomplete aspect for 74, it speaks to the concern that if you are 

elderly in this country and we get to a one-payer system, there will 

be decisions made not based upon health care but on cost, and I 

yield back my time. 

Mr. PALLONE. Thank you. 

Chairman Waxman. 

Mr. WAXMAN. Thank you, Mr. Chairman. 

The health care bill that the Republicans are complaining about 

is not law yet your agency, the Preventive Task Force, is an operation. Is it set up under law? 

Dr. CALONGE. Yes. 

Mr. WAXMAN. And your job isn’t to make recommendations to insurance companies, is it? 

Dr. CALONGE. That is correct. 

Mr. WAXMAN. Your job is to make recommendations on preventive services so that the latest science and information about the 

science is communicated to clinical practitioners. Isn’t that your 

job? 

Dr. CALONGE. That is correct. 

Mr. WAXMAN. And this is very useful information. Now, we are 

focused on the breast cancer issue, but that is not the only area 

where you have made recommendations. Isn’t that true? 

Dr. CALONGE. That is correct. 

Mr. WAXMAN. How many other areas has the task force made 

recommendations in the last couple of years, let us say? 

Dr. CALONGE. Well, our current portfolio is 105 total and we take 

up around 15 new or updated topics annually. 

Mr. WAXMAN. You have recommended that teenagers be screened 

for mental illness? 

Dr. CALONGE. Yes, that was a new recommendation this year, 

Congressman, that we just came out with, so this is new services 

that have not been recommended prior. 

Mr. WAXMAN. And there was a breast feeding behavioral intervention recommendation? 

Dr. CALONGE. That is correct. 

Mr. WAXMAN. And you have had a recommendation that aspirin 

for the prevention of cardiovascular disease be a way to prevent the 

disease. Is that right? 

Dr. CALONGE. That is correct. 


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Mr. WAXMAN. So you have had a whole range. You say how 

many, 103? 

Dr. CALONGE. A hundred and five total. 

Mr. WAXMAN. A hundred and five total. I am assuming that none 

of the others have been as controversial as this particular one. 

Dr. CALONGE. That is correct. 

Mr. WAXMAN. So we have a controversial issue because it challenges the accepted notion about the frequency of breast cancer 

screening and we are going to hear a lot more about that from the 

next panel. But I want to have us look at the challenges being 

raised by some of the Republicans, which I think is all political. 

They are acting as if your recommendations based on bringing the 

scientists who have the expertise which are directed at clinical people will be used to ration care. That is their argument: we are 

going to ration care. And then they say well, that is because there 

is going to be a health care bill that will provide a requirement for 

minimum benefits. Now, there will be minimum benefits in that it 

should have access to hospitals, it should have access to doctors, 

have access to pharmaceuticals. Your area is in the preventive area 

and nothing could be more important to me than having the latest 

science on how to prevent diseases, because if we can prevent illnesses, we won’t have to treat them later. Your task force will continue in operation. You will convene the scientists who are experts 

in different areas of prevention. 

Now, I guess the question, I am not 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 legislation process. It certainly would be private insurance. Right now private insurance doesn’t have to abide by your recommendations. 

Isn’t that true? 

Dr. CALONGE. That is correct. 

Mr. WAXMAN. And some of them cover these preventive services 

and some of them don’t. Isn’t that true? 

Dr. CALONGE. That is correct as well. 

Mr. WAXMAN. It is their decision. But if we are going to provide 

subsidies for people to get insurance and we are 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 that don’t provide any minimum benefit at all. They can be cheaper if they don’t 

provide minimum benefits. Well, I find that troubling. But let us 

say we are 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? 

Dr. CALONGE. Congressman, I am not well—— 

Mr. WAXMAN. You are not an expert on the bill. 

Dr. CALONGE. That is correct. 

Mr. WAXMAN. But let me explain what the bill will do. The new 

bill will take your recommendations. They will go to the Secretary. 

The Secretary will review them. The Secretary will have a notice 

of rule and comment and a public process and then decide whether 


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that is a minimum benefit. Now, a minimum benefit is a minimum 

benefit. It is not a maximum benefit. So if there is a recommendation as you proposed on breast cancer screening, that will be not 

a requirement of insurance to do no more than that, it will be a 

recommendation that will require insurance companies to do that 

as a floor, not a ceiling. I just wanted 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 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 between insurance plans to be those 

that cover breast cancer screening and those who don’t, but those 

are at least a minimum of preventive services that we can hope 

will prevent diseases and need for paying for care for those diseases. 

Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you, Chairman Waxman. 

Next is the gentleman from Texas, Mr. Burgess. 

Dr. BURGESS. Thank you, Mr. Chairman. 

Let me ask you a question. I have got the 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. Preventive Services Task Force, and a number of individuals 

are listed there. Their specialties are not. Is anyone on the list 

there a board-certified OB/GYN? 

Dr. PETITTI. Yes, there are two board-certified OB/GYNs on the 

task force, and that is a usual—we usually have two. 

Dr. BURGESS. Which are those two that are on the list that I 

have in front of me? 

Dr. PETITTI. Kimberly Gregory and Wanda Nicholson. 

Dr. BURGESS. And they both participated in this decision? 

Dr. PETITTI. Kimberly Gregory was on the task force when this 

decision was voted; Wanda was not. There was another OB/GYN on 

the task force when this topic was voted. That was George Siwaya, 

who is a professor of OB/GYN at University of California-San Francisco. 

Dr. BURGESS. Were these unanimous votes? 

Dr. PETITTI. No, the votes were not unanimous. 

Dr. BURGESS. Do we know how the individuals voted? 

Dr. PETITTI. I can’t recall. That is in the record, and we could 

make that information available to the committee if that is important. 

Dr. BURGESS. I would like to see it. I don’t know if the committee 

will deem it as important, but I would certainly appreciate the opportunity to see it. 

Now, is there a radiologist in this group? 

Dr. PETITTI. No, there is no radiologist in this group. 

Dr. BURGESS. Is that a problem? 

Dr. PETITTI. 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 

reviewed the documents and the recommendations and provided 

input. 


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Dr. BURGESS. On this task force, the majority of these individuals were primary care doctors. Was there a general surgeon on 

the task force? 

Dr. PETITTI. Well, again, the experts are experts in primary care 

and prevention, and yes, there were, and I would have to count 

them, four primary care physicians on the task force currently and 

four at the time that these were voted. 

Dr. BURGESS. But was there a general surgeon who specializes 

in—— 

Dr. PETITTI. No, there was no—— 

Dr. BURGESS [continuing]. Needle localization and breast biopsy? 

Dr. PETITTI. No, there wasn’t. They were consulted. 

Dr. BURGESS. They were consulted. All right. And I apologize for 

being in and out but we are doing nine simultaneous hearings 

today and the financial services makeover requires some attention 

and thought as well. On the issue, though of talking about—you 

said you factored in the psychological events surrounding a callback on a positive mammogram. You factored in the psychological 

cost, if you will, to the patient in that exchange. Do I understand 

that correctly? 

Dr. PETITTI. Well, the issue was a qualitative assessment. Anxiety, psychological distress, inconvenience are all considered to be 

harms and potential harms, and again, it is a part of the net benefit equation. 

Dr. BURGESS. When I was I school back in the 1970s, I realize 

it was a long time ago, but mammographic screening was not, at 

least in the area that I went to school, that was not something that 

was done. You sent someone for a mammogram, it was kind of a 

big deal because you felt something, but it wasn’t done as just part 

of a routine screening. In fact, I don’t think, as I recall looking 

back, it was probably the mid-1980s when that became a standardized screening test, and in fact in Texas, I don’t know whether this 

is true nationwide but in Texas I know women can self-refer for 

mammography. When that all happened, 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 

have come to the point now where we rejected it back in the 1980s 

but now in 2009 this is a factor again that is worthy of our consideration? 

Dr. PETITTI. Again, this is not determinative. It is information 

that we want women to know about. We want them to know how 

common it is. Again, the false positive rate is much lower as 

women get older and that is part of the net risk benefit equation. 

We would not want women to be afraid of having mammography. 

This is again one piece of information that women and their physicians should discuss when decided when to start screening. 

Dr. BURGESS. And does that same rationale apply to self-examination? 

Dr. PETITTI. The task force recommended against clinicians 

teaching women breast self-examination. They did not recommend 

that women not pay attention to their bodies, that they ignore 

lumps or that they ignore problems that might come up when they 

find a lump. Again, the task force recommendation was against 

doctors teaching women breast self-examination. 


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Dr. BURGESS. Well, how are women supposed to get that knowledge? If they can’t just get it by intuition, someone along the line 

has got to provide them some guidelines on proper time to do the 

exam and how to do it and what to be concerned about and what 

not to be concerned about. As I recall, and I may be wrong on this 

but I don’t ever recall coding and being compensated for teaching 

breast self-exams so it is not a—I mean, I wasn’t a cost center for 

you. I wasn’t a cost driver. My only inference from that could be 

that you are worried that people will find things that then lead to 

procedures and we are better off if we don’t ask, don’t tell. 

Dr. PETITTI. Again, the evidence—there have been two very wellconducted 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 mortality from breast cancer. 

Again, we go to the evidence. 

Dr. BURGESS. Well, and I will say anecdotally—— 

Mr. PALLONE. The gentleman’s time has expired. 

Dr. BURGESS [continuing]. As I said in my opening statement, it 

does strike me—— 

Mr. PALLONE. Mr. Burgess, you are 2 minutes over. 

Dr. BURGESS. It does strike me that the amount of disease—— 

Mr. PALLONE. Mr. Burgess. 

Dr. BURGESS [continuing]. The amount of disease that was 

brought to my attention by the patient herself, and again—— 

Mr. PALLONE. Dr. Burgess, your time has expired. 

Dr. BURGESS. I will just be interested in what some of the other 

clinicians tell us when they get their chance to testify. Thank you, 

Chairman. 

Mr. PALLONE. Dr. Burgess, you are almost 3 minutes over and 

we are about to vote. 

I think we have time for one more set of questions and then we 

are going to vote. We have five votes. We will take one more set 

of questions and then we will adjourn and come back after the five 

votes. Next is—Chairman Dingell, did you want to proceed now? 

Mr. DINGELL. I think I can proceed rather quickly, Mr. Chairman. Yes, please. 

I would like to welcome you both to the committee and tell you 

how helpful it is to have you here. From the things I have heard 

said on the other side of the aisle about you folks at the agency, 

I was afraid you would appear with horns, tail, fangs and in a red 

suit breathing fire demanding that we immediately terminate all 

health benefits for the unfortunate, sick, weak, poor and especially 

with regard to mammograms and Pap smears. So I am very much 

comforted and I want to welcome you to the committee this morning. 

I just have really one question that I think is important. I find 

it curious that the task force has repeatedly over the years voted 

to leave costs out of its deliberations on whether to provide or not 

approved preventive service. Why? 

Dr. CALONGE. Thank you, Congressman. I think this is a key 

question. The task force believes its major charge from Congress 

and responsibility to primary care clinicians and patients is that 

we set the evidence-based stake in the ground immune from how 


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much it costs to achieve the benefits associated with a given effective preventive service. So—— 

Mr. DINGELL. So your short answer is, that you are recommending the needed services, the needed tests, the needed treatments as opposed to looking at the cost. Is that it? 

Dr. CALONGE. That is correct. 

Mr. DINGELL. Okay. Now, to assist my colleagues on the other 

side of the aisle, and I do this out of great affection and respect 

and charity, you address this question in your statement and you 

say here, and I will read this for the benefit of my colleagues on 

the other side, you say, ‘‘Task force recommendations are based on 

consideration of the health benefits and health harms of providing 

the preventive service and on the scientific certainty of whether the 

preventive service works. Cost effectiveness of specific prevention 

services are not addressed by the task force in its deliberation.’’ 

Then you say this: ‘‘The task force only—’’ and that is underlined 

‘‘considers scientific evidence of health benefits and health harms. 

The task force has specifically discussed whether cost should influence a recommendation and has repeatedly voted to leave costs out 

of deliberations on whether or not to provide a preventive service.’’ 

Is that right? 

Dr. CALONGE. That is correct. 

Mr. DINGELL. Now, when your recommendations are made, are 

they used to put a ceiling on benefits or are they used to describe 

a minimum level of benefits that people should get? 

Dr. CALONGE. Congressman, I must admit that it is outside of 

the scope of our recommendations how they are used by other entities. 

Mr. DINGELL. Okay. Now, your recommendations are not expected to be substituted for the need of the patient or the concerns 

and expertise of the doctor, and they are not intended to intrude 

into the doctor-patient relationship. Am I correct in that interpretation or am I wrong? 

Dr. CALONGE. That is correct. In fact, if you read our statement 

that is published in the annals, it says, ‘‘The task force recognizes 

the clinical or policy decisions involve more considerations than 

this body of evidence alone. Clinicians should understand the evidence and individualized decision-making to the specific patient or 

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 for his or her best interest. 

Mr. DINGELL. Now, you do permit as the task force goes about 

its business to have different agencies and persons of concern 

present in the deliberations. Is that not so? 

Dr. CALONGE. That is correct. 

Mr. DINGELL. And your deliberations are public? 

Dr. CALONGE. At this point, the deliberations of a task force vote 

are by invitation only. 

Mr. DINGELL. By invitation, but you don’t gag the people who 

come in to listen. They can go out and say what is going on and 

they also are permitted to make comments to you on the task force. 

Is that not so? 


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Dr. CALONGE. We actually invite comments from our partners to 

help us do our job better and to take into consideration different 

viewpoints and different issues. 

Mr. DINGELL. And you allow citizen input? 

Dr. CALONGE. The task force is currently moving towards increased private-citizen input with the resource 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 are important stakeholders. This is an issue 

that the task force believes that in the interests of enhanced transparency and responsibility to the American public and the patients 

whose physicians may consider our recommendation needs to be 

improved. 

Mr. DINGELL. Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you, Chairman Dingell. 

We have five votes, I would say about an hour, but when they 

are done we will come back and reconvene. The committee stands 

in recess. 

[Recess.] 

Mr. PALLONE. Thank you both for being here. We now go to a Republican member, Mr. Gingrey. 

Dr. GINGREY. Mr. Chairman, thank you, and I thank the witnesses. 

My first question kind of pertains to what Dr. Burgess, Dr. 

Petitti, was asking you a little bit earlier about how many OB/ 

GYNs there currently are on the task force. I wanted to specifically 

ask you though how many GYN oncologists serve as members of 

the task force when the recommendations were promulgated—GYN 

cancer specialists. 

Dr. PETITTI. There are no GYN cancer specialists on the U.S. 

Preventive Services Task Force. 

Dr. GINGREY. Well, let me read to you from testimony that we 

are going to hear from the second panel, in fact, the president of 

the National Breast Cancer Coalition, Fran Visco, Attorney Fran 

Visco, where she states in her testimony, ‘‘We want to note that the 

attacks against the makeup of the task force are misplaced. Screening is an issue of primary care. It is a health intervention for a 

healthy population. The experts in this area, those with the scientific training and objectivity to do the necessary analyses are primary care health professionals and methodologists such as epidemiologists and biostatisticians, not radiologists or medical 

oncologists.’’ And I am quoting directly from her statement, which 

we will hear later. What is your opinion on that? 

Dr. PETITTI. The task force expertise in this area was sufficient 

to weight the evidence that led to its recommendations. The recommendations are made by the task force with the input of a variety of other specialty groups. They are not made in a vacuum. In 

this case, they were submitted to, I can’t remember the number of 

partner organizations but it was at least 10. Each of these partner 

organizations sent them out to experts. Those experts provided 

written opinions. 

Dr. GINGREY. And some of those experts then would be cancer 

specialists? 

Dr. PETITTI. Yes. 


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Dr. GINGREY. Female-cancer specialists? 

Dr. PETITTI. There was—— 

Dr. GINGREY. So by that response, I guess you would take exception to the comments by Ms. Visco, but we will hear from her later. 

Let me ask you another question. On your website—and either 

you or Dr. Calonge—on the USPSTF website, it clearly states that 

the United States Preventive Services Task Force recommends 

against routine screening mammography in women age 40 to 49 

years. Do you think that this statement could be perceived by 

women younger than 50 that they should not get a mammogram? 

Dr. PETITTI. We need to immediately figure out how to get that 

statement off the website. I think it could be misconstrued. It has 

been misconstrued and we need to fix our website. 

Dr. GINGREY. Dr. Petitti, I thank you for that response, and I 

hope that you will do that. I think it is very important. I agree 

with you. 

I want to ask you, Dr. Calonge, are you aware that the Senate 

version of health care reform, specifically section 4004, I think it 

is on page 1,150, that requires the Secretary of HHS 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 those you recommend against, the C’s and D’s? Do you think 

that this national awareness campaign could be perceived by 

women younger than 50 that they should not get a mammogram 

or perform a breast self-examination? 

Dr. CALONGE. I wonder, Congressman, if it would be okay if you 

restate your question, because the first part of it and the second 

part I didn’t—— 

Dr. GINGREY. Well, what I am 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, and I named 

the page and section, that the Secretary would require the creation 

of a national prevention awareness campaign, television ads, TV 

spots based on all the task force recommendations both those that 

you 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 50 that they should not get a mammogram nor should they perform breast self-examination? 

Dr. CALONGE. Thank you for the clarification, Congressman. So 

I can’t speak specifically to the bill or to the policy. I will speak 

to the communication of the recommendation which we believe 

needs to focus on the decision to start regular biannual screening 

before the age of 50 should be an individual one and take patient 

context into account including 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 that clear message of 

what the task force intended needs to lead that, not follow. 

Dr. GINGREY. Thank you, Doctor. 

Mr. Chairman, if you will bear with me just for maybe 15 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 in women 


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40 years or older. That is saying that you don’t recommend that 

the clinician, a physician, primary care physician, OB/GYN specialist, should routinely do a breast examination as part of a complete physical in her or her patients, that that has no value? 

Dr. PETITTI. The evidence does not provide support for a clinical 

doing a clinical breast examination. 

Dr. GINGREY. Well, I thank you for that response and your honesty. 

Mr. Chairman, I know I have gone beyond my time. I appreciate 

your patience. I think that is terrible and something needs to be 

done about that. 

Mr. PALLONE. Next is our vice chair, the gentlewoman from California, Ms. Capps. 

Mrs. CAPPS. Thank you, Mr. Chairman. 

I just want to say thank you to both of you for being here, for 

your excellent testimony and being among the few on Capitol Hill 

who apologize occasionally, and it is not a habit that we do very 

well so the fact that you—I wouldn’t call it an apology as much as 

acknowledging the communication glitches that occurred perhaps, 

and for me, I think it was a lot of was timing, but I don’t take it 

as a negative thing. I think we are seen 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 it as a teachable moment. Let us 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 in widely misconstrued ways, and I want to 

take a minute of my time to mention one very important distinction but it is also an important point of what the health care reform bill is, which actually will be augmenting a lot of the preventive work that you are doing because women will be able to have 

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 11 benefit categories including inpatient hospital services as examples, outpatient services, maternity care, prescription drugs as 

well as preventive services. But with regard to preventive services, 

the bill says that the recommended items and services with a grade 

of A or B from U.S. Preventive Services Task Force shall be covered as part of the essential benefits package, a rightful designation of the importance of your studies and your recommendations, 

but not a conclusive piece of it, and they said this be something 

which we highly recommend that there be no cost sharing for this 

grade A and B of your recommendations. The benefits advisory 

committee, part of the health reform, will be able to recommend 

through its public standard-setting process that additional preventive services such as mammograms for women under 40 or between 

40 and 49 be covered without cost sharing. I mean, there is an additional recommendation that can come as part of the bcc bill. The 

Secretary may also approve such coverage. The essential thing here 

is that the benefits package, the essential benefits package is a 

floor, not a ceiling, and that really is important. I want the record 

to state that very clearly. Once the exchange goes into effect and 

there is real competition between private insurance plans, they 


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may wish to offer more-attractive packages to win more, you know, 

coverage so it may be understood more fully as we go along this. 

I just wanted to make sure that is in the record. 

But I wanted to give you even more opportunity, both of you or 

one of you, to talk about what the future could hold. You see, I 

think this is an opportunity, 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 set of recommendations like yours comes out, that 

there is 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 am only giving you about a minute but I would like you to 

elaborate further on ways that your task force can communicate in 

the future in ways that maybe we can access and use more efficiently. 

Dr. PETITTI. Well, 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 stratification. 

What I thought is, it might initiate a dialog 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—— 

Mrs. CAPPS. Absolutely. 

Dr. PETITTI [continuing]. Are younger and women of Ashkenazi 

Jewish 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-stratified decision making and not this sort of rehashing of a 

bunch of old data. 

Mrs. CAPPS. Dr. Calonge, would you like to add anything to that? 

And I know I am squeezing a few more seconds. I think this is really important. 

Dr. CALONGE. I want to echo the issue about individualized decision making. We hear a lot about personalized medicine and I 

think the basis of personalized medicine can be and should be individual based decision making, and it is really what we were hoping 

the language for the younger age group would start engendering, 

this issue about, you know, we as consumers of health care should 

kind of understand that every test we have and every treatment 

we have has both inherent risks and benefits and we should make 

our decisions based on understanding those and then what is important to us. 

Mrs. CAPPS. 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 in the area of health a population that can seize the 

material as well as primary care providers and others doctors, you 

know, use your information every single day to make the kind of 

informed decisions that they and their patients 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 

of and use your expertise and your research and have this kind of 


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debate, if you will, but discussion. So I thank you again for being 

here. 

Mr. PALLONE. Thank you. 

Mr. Rogers. 

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? 

Dr. PETITTI. No. 

Mr. ROGERS. So you knew nothing about the over a dozen references to your task force in this bill? 

Dr. PETITTI. You know, I hate to say, but I was busy preparing 

a course in biostatistics, and the answer is honestly no. 

Mr. ROGERS. And is that consistent through the whole task force 

or any of its representatives or administration thereof? 

Dr. CALONGE. I hesitate to have the two of us represent the opinions of all the task force. 

Mr. ROGERS. But it wasn’t part of your discussions? 

Dr. CALONGE. In July? Absolutely not. 

Mr. ROGERS. Are you aware that in this particular bill, and I 

think maybe our Health Committee chairman was mistaken and I 

think the chairman emeritus was mistaken. This is not necessarily 

a new committee. They may create a new name but in the bill— 

and I will just read right from the bill. ‘‘The preventive services 

task force convened under section 915A of the Public Health Service Act and the Task Force on Community Preventive Services, and 

then in quotation marks ’’as such section task forces were in existence the day before the day of the enactment of this Act shall be 

transferred to the Task Force on Clinical Preventive Services and 

the Task Force on Community Preventive Services, respectively, established 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? 

Dr. PETITTI. Well, certainly—— 

Mr. ROGERS. Yes or no. I am sorry. 

Dr. PETITTI. Yes, I am now aware of it. 

Mr. ROGERS. But were you aware of that during your deliberations? 

Dr. PETITTI. No. 

Mr. ROGERS. Would that have changed your deliberations at all? 

Dr. PETITTI. I can’t speculate on what might have happened. 

Mr. ROGERS. Interesting. So what you are saying is that according to the law of which this committee wants to enact you have 

now taken ages 40 to 49 and made them a category C which means 

they will not be paid for under this committee. That is interesting. 

Now, let me ask you this. You say you didn’t consider cost. Is 

every appendix that is attached to your task force recommendation, 

is that something that would have been reviewed by the individuals who made the determination? Is that something of value? 

That is why you attached it as an appendix, I imagine? 

Dr. PETITTI. Yes, all the material and evidence is germane to 

the—— 

Mr. ROGERS. Thank you very much. Are you familiar with appendix C1 where the question is, what is the cost effectiveness of 


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screening, that assigns a dollar value by quality of years of life? 

Are you familiar with this? This clearly is a cost-effectiveness portion of your study. Clearly you cannot in good conscience 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 quality of life and it is done on mammography 

screenings. 

Dr. PETITTI. The committee—— 

Mr. ROGERS. Will you remove this from your task force study as 

well as your recommendation that said—— 

Dr. PETITTI. I am sorry but I am trying to see what you are 

pointing at, and I—— 

Mr. ROGERS. It is appendix C1 of your own task force 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 are going to 

take that off. That is great. You say that gee, we didn’t consider 

cost but on your own report it says you considered costs. You can 

see why after we are creating 118 brand-new commissions just like 

yours all of your authority will now be enacted into law according 

to their own bill by the reference I have just read. I mean, it is 

pretty serious. 

And let me ask you another question. As a part of this, it says, 

and I am 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 health care section, section 206, I 

would encourage you to read it, under mammography and other 

cancer screening, ‘‘The Secretary shall ensure that screening provided for under this paragraph complies,’’ meaning you have got to 

do it ‘‘with the recommendations of the task force with respect to, 

A, frequency, B, the population to be served, and C, 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. 

Would that change your consideration as a scientist knowing by 

your own testimony it did not pass unanimously? You say science 

and evidence but clearly people equally learned as both of you believe that that was the wrong answer? Is this something you 

should reconsider? 

Mr. PALLONE. Mr. Rogers—— 

Mr. ROGERS. I would like an answer to my question. 

Mr. PALLONE. No, I know, but I am going to ask you to go beyond 

that. I mean, you used your 5 minutes. Take what time is necessary to respond because I am not sure you even know what the 

questions are, but please take your time. 

Dr. PETITTI. I was going to say that. 

Mr. ROGER. I got my yes and no’s. 

Dr. PETITTI. There were a number of different questions and I 

am 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 for the 

recommendations for mammography screening A, B and C, we 


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voted them without regard to cost or cost-effectiveness analysis. I 

can say honestly, absolutely, the word ‘‘cost’’ was not in the room. 

It was not mentioned. It was not uttered and it did not in any way 

determine—— 

Mr. ROGERS. 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 C1 considers cost. How 

could you—— 

Mr. PALLONE. Mr. Rogers’ time is up, but you can respond and 

say what you want but we have got to move on. 

Mr. ROGERS. I have more questions, Mr. Chairman, if you would 

like. 

Dr. PETITTI. I have nothing more to say. 

Mr. PALLONE. Mr. Rogers, I am just trying to make sure she is 

able to respond, but I think we should move on because we are a 

minute over now and she doesn’t want to say anything else. 

Mr. ROGERS. Well, Mr. Chairman, my only caution here is that— 

and I—— 

Mr. PALLONE. I understand what you are—— 

Mr. ROGERS. No, I do believe the intention of the other side is 

real. I do believe that. But the language of the bill of which I believe that most Members of Congress have not read—— 

Mr. PALLONE. But she has repeatedly said 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 President of the United States, so—— 

Mr. ROGERS. But, Mr. Chairman, the point here is that she did 

say that cost wasn’t part of their voting but it certainly was part 

of their report. That is very important knowledge for all of us to 

know when we raise questions about adding—when you—— 

Mr. PALLONE. You made your statement. She responded to it. Let 

us move on. I can’t help but repeat that their deliberations, as I 

said, even preceded the current Administration. But whatever, let 

us move on. 

Next on the Democratic side is the gentlewoman from the Virgin 

Islands, Ms. Christensen. 

Mrs. CHRISTENSEN. Thank you for your presentations and your 

answers thus far. I want to go back to the issue of African American women. Some years ago, many of us worked to ensure that 

mammograms be recommended and covered for women of African 

descent under age 40, and given that even though we may have a 

lower breast cancer incidence, we are 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 

rather than lumping all women between 40 and 49 or younger 

under C or I? 

Dr. PETITTI. You make an excellent point, and I think again what 

I expected to happen with these recommendations is that we would 

begin to focus on how to make more stratified and nuanced recommendations that would identify those groups who are unrecogVerDate Mar 15 2010 03:42 Sep 19, 2012 Jkt 074856 PO 00000 Frm 00083 Fmt 6633 Sfmt 6633 E:\HR\OC\A856.XXX A856

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nized as being at higher risk of consequences of breast cancer when 

diagnosed at a young age. 

Mrs. CHRISTENSEN. 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 maybe a different grade for different age groups in that particular age group and make that recommendation. Might that not 

happen? 

Dr. PETITTI. Yes. I think that the accompanying editorial to our 

recommendations pointed the direction that we thought we would 

be going, you know, not in Congress trying to defend them but 

moving to the point where we have more individualized risk, and 

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. Again, 

we need to do better at the risk stratification and individualized 

risk. I can’t say the task force will immediately be able to go back 

and— 

Mrs. CHRISTENSEN. I understand, but you recognize it, and this 

is not the final answer? 

Dr. PETITTI. This is definitely not the final answer. I think people 

would have wished that we would have not even ever opened this 

topic again after 2002. 

Mrs. CHRISTENSEN. Especially not right now. 

Dr. PETITTI. That was an accident. 

Mrs. CHRISTENSEN. But given what occurred in response to the 

article and the press taking it up and how it has been interpreted, 

have you looked at other ways of presenting recommendations that 

might be controversial? I have 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 medical journal because they don’t really 

understand it. 

Dr. PETITTI. Well, we communicated very poorly. We should have 

spent more time talking with our stakeholder groups. We should 

have had a formal communication plan both to consumers and physicians. 

Mrs. CHRISTENSEN. I agree. Can you explain how the overdiagnosis—it is a bit confusing but can you explain how overdiagnosis 

occurs when DCIS or early-stage lesions, especially in younger individuals is diagnosed and treated? Because my understanding on 

the DCIS is that it is likely a precursor to invasive cancer, so is 

the task force that it might be better to not diagnose it or if you 

think it is there to leave it alone and not do further investigation 

or remove it? Because I would think—anxiety is one of the issues 

that you raised. I would think it would be more anxiety provoking 

to think that I had a CA in situ or early-stage cancer and sit and 

wait on it rather than to have it biopsied and removed. 

Dr. PETITTI. Well, here we are definitely getting way out of my 

range of expertise. This is a topic which I would want to have addressed by 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 and those tumors 


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that aren’t going to progress, but this is outside my area of expertise. 

Mrs. CHRISTENSEN. Well, speaking to surgical oncologists actually yesterday, they feel that DCIS is many times a precursor to 

invasive cancer and I am surprised that it is listed as one of those 

things that maybe we are overdiagnosing or overtreating, but I 

think my time is up, so thank you for your answers. 

Mr. PALLONE. The gentleman from Arizona, Mr. Shadegg. 

Mr. SHADEGG. I thank you, Mr. Chairman. 

First, I have to express some sympathy for you. You have 

stepped into a controversy which has been made much larger as a 

result of the overall health care reform that is going forward, and 

I think that to a certain degree you have 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 is what we have concluded based on that 

science, it shouldn’t be automatic, it ought to be something you 

think through and here is our recommendations. That makes a lot 

of sense to me. I presume from 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 of the 

categories where you didn’t feel it should be automatic but under 

those circumstances it should occur. Is that correct? 

Dr. PETITTI. Yes, that is correct. 

Mr. SHADEGG. Okay. 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 their doctor or looking 

at their family history thought she needed it, that would make that 

at least not an insurable event, correct? 

Dr. PETITTI. I am not here to get involved in the coverage and 

health care reform coverage issue. 

Mr. SHADEGG. 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 able to prohibit someone from offering mammogram coverage or as an insurance company or a public plan nor should it be able to prohibit an individual women 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 into which your work has been reported, does 

precisely that. 

I do want to say that it is important, Mr. Chairman, that facts 

be abided by and unfortunately, in a piece of legislation this size, 

it is subject to interpretation and it is 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 by there have been 

things stated in this room today that are flat untrue. For example, 

the chairman said that if a C option—you have your A and your 

B and now a C—is determined by the Secretary to be covered, it 

is to be covered. That is in fact flat not true. The only way a C option can be covered under the language of this bill is for two things 

to happen. First, the Health Benefits Advisory Committee has to 

say contrary to what the bill says we think it should be covered, 


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and then the Secretary has to say it. So it not a single decision by 

the Secretary. 

Second, and I am sorry he is 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 prescribes 

minimum benefits and therefore to say that coverage of mammograms is not prohibited is untrue, that all the bill does is prescribe 

minimums. That also is flat not true. If you go to page 169 of the 

bill passed by the Congress, you will discover, as I mentioned earlier, that there are four levels of plans. There is a basic plan, an 

enhanced plan, a premium plan and a premium plus plan. The 

basic plan can only cover A’s and B’s, the things you recommend 

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 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 benefits. They say 

you can have an enhanced plan and you can have lower cost sharing. You can have a premium plan and it can have lower cost sharing 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 full committee to page 

169, lines 20 through 25, does it say a premium plus plan is a premium plan that also provides additional benefits. That is 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 are offered by the government 

or offered by a private insurance company. Whether they are in the 

public plan or in a private plan, they are prohibited, and that may 

not be the intent. As the ranking member, Mr. Barton, made very 

clear, we need to deal not with 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 minimums. 

There are words at the beginning of the bill which refer to minimums but the words of the bill 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 a C, and I appreciate the opportunity to put that into the record. Thank you, 

Mr. Chairman. 

Mr. PALLONE. Thank you. I don’t want to keep belaboring the 

point but the reason I responded to your statement and said that 

there were situations where the Secretary, and now you are saying 

advisory commission could add it to a basic benefit package was because when you made your opening statement you suggested that 

it couldn’t be done that way, that they couldn’t include it. So I don’t 

want to belabor the point. I don’t disagree with you but you are 

disagreeing with yourself because you initially said that they 

couldn’t add it as a basic benefit, and now you are saying they can. 

Mr. SHADEGG. If the gentleman would yield? 


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Mr. PALLONE. Sure. 

Mr. SHADEGG. I actually didn’t say they couldn’t add it. I didn’t 

discuss whether they could add it. I said that the basic plan cannot 

offer it, and it cannot offer it absent extraordinary circumstances, 

which are two other things. 

Mr. PALLONE. See, I think—— 

Mr. SHADEGG. And I think what we are—— 

Mr. PALLONE. I think the problem is, we are saying the same 

thing but I am not going to get into it. I don’t think there is any 

difference between what you said and what I said. 

Mr. SHADEGG. Let us agree on that, but let us agree to fix it so 

that the bill doesn’t say that someone cannot choose to buy a 

plan—for that matter, let us allow people who get a public plan to 

get mammogram coverage. 

Mr. PALLONE. I am not going to continue to belabor it because 

I think that we are not necessarily disagreeing on whether it could 

or could not be included. 

The next person is the gentlewoman from Florida, Ms. Castor. 

Ms. CASTOR. Thank you, Mr. Chairman, and thank you very 

much for your testimony today. I believe the larger issue is the lack 

of access to any screening or health service for millions of American 

women of all ages, and I would like you to comment upon the implications of your latest recommendations on the millions of women 

who are not being screened at all. What do you say to them no 

matter their age? 

Dr. PETITTI. You know, again, the task force can’t fix these problems. I am here as a member of the task force speaking to mammography guidelines and speaking to the evidence we used to make 

them. There are clearly huge issues facing this country about 

health care and health insurance and health policy but I am not 

an expert in that area. 

Dr. CALONGE. If I could just add to the point that it is clear that 

the provision of mammography and screening for breast cancer extends life, and so that is the service that we recommend, and I 

think everyone in the room knows that and needs to keep in mind 

that if the idea is to maximize health and extend life, then the 

services that are recommended should be considered for provision. 

Ms. CASTOR. I mean, your recommendations talk about how, for 

example, the age 40 to 49, how it is important for women and their 

doctors 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 have—they are not receiving their checkups. Certainly you all have something to say to women all across 

America no matter their age on being as proactive as they can in 

taking personal responsibility, finding—you must have something 

to say on higher risk groups to help us communicate in a better 

way. You have already acknowledged that you did not do the job 

in communication but here is your chance today to bring all of your 

expertise and to provide a message to women on the importance of 

taking personal responsibility and getting their screenings. They 

may not have access to care but there are wonderful nonprofit 

groups where they provide some services in communities. Can you 

at least go that far and provide a proactive message to women in 


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this country on the importance of taking care of themselves and 

seeking out these screenings? 

Dr. PETITTI. Well, again, I feel uncomfortable in being asked to 

put on a personal hat rather than my task force hat. I would be 

remiss if I didn’t encourage women to be interested in their health, 

to take care of themselves, but I am here as a member of 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 who 

can’t get surgeries they need. But that is not my role here. My role 

here is to speak to the mammography guidelines. 

Ms. CASTOR. You are familiar with the huge disparities in 

screening, diagnosis and treatment among various income levels 

and if you are African American, you are a Latina, correct? 

Dr. PETITTI. There are disparities in health care throughout all 

services. 

Ms. CASTOR. If you could go back or will you go back and review 

your recommendations along the lines of higher risk groups, what 

we know in disparities of screening, diagnosis and treatment? Don’t 

you think you could have done a better job in fleshing out some of 

those recommendations? 

Dr. PETITTI. I think on many levels we know we could do a better 

job and among them is communication. We need 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 thought would happen 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 tailored. 

Ms. CASTOR. Thank you. 

Dr. CALONGE. I would only add to that a plea for consideration 

of research of preventive services in the specific populations who 

are underrepresented in screening and other prevention studies. 

We often fail in this area, and I will inform the committee that we 

had a discussion about health disparities associated with nearly 

every recommendation vote, and the frustration on our part is the 

lack of evidence of efficacy 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 researchers and funders of research to consider adequate studies that 

include disparate groups for where we are concerned there may be 

differences and require different recommendations. 

Ms. CASTOR. Thank you. 

Mr. PALLONE. Is the gentlewoman complete? All right. Thanks. 

The gentlewoman from Tennessee, Ms. Blackburn. 

Mrs. BLACKBURN. Thank you, Mr. Chairman. I guess you are not 

used to women speaking a little more quickly and being a bit more 

succinct and so maybe that is why we have time left many times. 

I want to thank you all for your patience and your endurance 

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 were and as we look at the language of the bills that 


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are before us, I think what we want to make certain we do is, if 

there is offending language in the bill, we want to get it out, 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 am 

going to try to be succinct on this because I do know you are ready 

to move on and we have another panel. Dr. Burgess asked that you 

submit the vote from your committee as you arrived at your finding 

and your guidance that you made public, and as you submit that 

vote, who voted and how, 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 studies, what findings, what groups. 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 that. 

I would 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 matrix 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 and how you 

worked, what your process is, how you 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 

have probably stepped into a bit of a quagmire that you did not expect as you released these findings, and I would like to ask you, 

were you all aware of how the H.R. 3962, how it would affect you, 

how your task force would be drawn into that bill, that the language of 3962 actually pulls you in, renames you and then gives 

credence to these findings through statute? 

Dr. PETITTI. Well, as unbelievable as it may seem to those who 

are so caught up in Washington, I was writing my biostatistics lecture and have been actually woefully and naively oblivious of what 

has been going on in the health care reform arena. Certainly from 

the point of view of specific statutory language in now what I know 

is a 2,000-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, the big vote, I was sort of stunned and then 

also terrified, and I think my being terrified was actually exactly 

the right reaction. 

Mrs. BLACKBURN. Dr. Calonge. 

Dr. CALONGE. I would like to add again speaking specifically to 

the timeline for the consideration of this recommendation that it 

was completed prior to any sense that the role of the task force 

might change under upcoming health care reform. I will say that 

earlier this year we became aware of language in the House bill regarding the recommendations of the task force. However, this recommendation was considered and voted on with our explicit scientific methods well before that. 

Mrs. BLACKBURN. I appreciate that, and I do thank you all for 

your sensitivity to this. I think the linkage that exists with the language of changing your title and then giving credence in the force 

of law basically to the priority assignments that you would make 

is of concern to us and to our constituents. I thank you all. And 


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I am only going to yield back 18 seconds but I yield it back, Mr. 

Chairman. 

Mr. PALLONE. Thank you. 

Oh, I am sorry. The gentleman from Ohio, Mr. Space. 

Mr. SPACE. Thank you, Mr. Chairman. 

Just so I understand this correctly, the task force has been 

charged with developing a scientifically determined floor for preventive services in this bill. Is that your understanding of your 

role? 

Dr. PETITTI. You know, I am realizing that I really don’t understand the bill. I shouldn’t speak to the bill. I have learned a lot 

about the bill here. 

Mr. SPACE. Well, the bill itself does in fact vest that kind of 

power with the task force to develop a scientifically determined 

floor, in 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—and by the 

way, the benefits advisory committee consists of private medical 

doctors, patients, employers, insurance experts, a dentist and representatives of relevant government agencies. It is chaired by the 

surgeon general. Once it issues its recommendations, the Secretary—those recommendations then are the floor. The Secretary 

then has the discretion to increase or enhance 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 package as established by this 

bill will not cover them is preposterous. There is no truth in it. 

I do have a specific question I would 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 that was very widely distributed regarding your findings that have created some confusion, and I’d ask that you try to clear this up for us. The author 

of this letter writes, this is a quote, ‘‘What is most troubling about 

the federal panel’s recommendations is that they are based mainly 

on cost saving.’’ She also expresses concern that the recommendations are ‘‘cost-saving measures.’’ Can you tell us today in no uncertain terms what the role of cost of mammograms played in your investigation and findings? 

Dr. PETITTI. This is an easy question. Cost played no role in our 

recommendations. Again, and I said it publicly in other settings 

and I will say it again here, I think I have said it three times here, 

cost was not a consideration in the voting of our recommendations. 

Mr. SPACE. Thank you. And finally, the author of that same letter pointed out that the task force contains ‘‘no cancer specialists.’’ 

This is obviously a point that would be disconcerting to many. Is 

it true that no member of the preventive task force have any experience in working with cancer? 

Dr. PETITTI. That is incorrect. Members of the task force consist 

of myself. I was the vice chair of the National Cancer Policy Board. 


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One member is a member of the National Cancer Institute Board 

of Scientific Counselors. Another member, current member is a professor of—he is the associate director of population sciences for the 

Dartmouth Hitchcock Comprehensive Cancer Center and an endowed chair of oncology. Again, the members of the task force have 

the expertise that permits them to make the kinds of recommendations they make within the arena of screening and preventive services. 

Mr. SPACE. Thank you, Doctor. 

I yield back my time. 

Mr. PALLONE. Thank you. 

The gentleman from Texas, Mr. Green. 

Mr. GREEN. Thank you, Mr. Chairman, and I will be as quick as 

I can. 

I want to welcome our doctors. I guess having served on this subcommittee for 12 years now and the release from the USPSTF 

probably got more coverage than anything our subcommittee has 

done except the health care bill, and there was a lot of misinformation about it. But in your testimony you say that the individuals 

representing the views of the American College of Obstetricians 

and Gynecologists and the American Academy of Family Physicians 

weighed in on your recommendations and the obstetricians and 

gynecologists expressed concerns with the wording of the recommendations. Do you believe in the future it would be a good idea 

for the task force to actually have individual organizations such as 

these as actual reviewers instead of commenters? 

Dr. PETITTI. Well, I want to clarify that they were official reviewers. First of all, as I pointed out, there were two members of the 

American College of Obstetrics and Gynecology on the panel. The 

ACOG reviewers were official reviewers. They made a number of 

comments. One of their comments which was the most substantive 

comment in retrospect was about their anticipation of 

misperception of our C recommendation, and they were right. And 

we should have listened more carefully to them and I am sure we 

will listen more carefully in the future. 

Mr. GREEN. And I think there was information I guess on the 

self-exam, and from your testimony earlier was that, you know, 

physicians need to be able to provide the expertise so women can 

do the self-exam, that it is not perfect. If there a question, then 

they ought to talk to their physician and that is where it goes from 

there. So that is why I don’t understand the fear of the self-exam. 

My last question is, a major concern I have is the lack of transparency of the process within the USPSTF for deciding whether or 

not to change or create new screening recommendations, and depending on what happens with the 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 have learned from this experience? 

Dr. CALONGE. 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 the previous Congresswoman 


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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 is a good step. We are cautiously trying to expand 

into areas of transparency to include potentially public commentary 

during meetings and other approaches that we believe meet the intent and the requirement for transparency so that the decisions are 

made in such a way that we are 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 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 are working towards that 

end. 

Mr. GREEN. Thank you. 

Thank you. Mr. Chairman. 

Mr. PALLONE. 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 has been in politics I guess I could say my 

entire life, I think it is kind of refreshing to find out that, you 

know, you really were very independent and not at all aware of 

what we were doing. I think we gives ourselves too much importance. We all think we are all so important, that everybody is paying so much attention to everything we do. It is kind of refreshing 

to know that you were not. Thank you. 

I will ask the next panel to come forward. Let me welcome our 

second panel and introduce the panel beginning on my left is Dr. 

Otis Webb Brawley, who is chief medical officer for the American 

Cancer Society, and next is Jennifer Luray, 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 Visco, who is president of the National Breast Cancer Coalition. I know some of you have been here before and thank you for 

being here. I won’t repeat that we ask you each to keep your comments if you can to 5 minutes. They become part of the record. And 

if you want to, you can submit additional written comments later. 

Let us start with Dr. Brawley. Thank you. 

STATEMENTS OF OTIS WEBB BRAWLEY, M.D., CHIEF MEDICAL 

OFFICER, AMERICAN CANCER SOCIETY; JENNIFER LURAY, 

PRESIDENT, SUSAN G. KOMEN FOR THE CURE ADVOCACY 

ALLIANCE; DONNA SWEET, M.D., M.A.C.P., MEMBER, AMERICAN COLLEGE OF PHYSICIANS’ CLINICAL ASSESSMENT EFFICACY SUBCOMMITTEE; AND FRAN VISCO, PRESIDENT, NATIONAL BREAST CANCER COALITION 

STATEMENT OF OTIS WEBB BRAWLEY 

Dr. BRAWLEY. Good afternoon, Mr. Chairman and distinguished 

members of the committee. I am Otis Brawley, the chief medical 

officer of the American Cancer Society. On behalf of the 11 million 

patients and survivors in America today, the Society thanks you for 


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your continued leadership in the fight against your cancer and your 

commitment to enacting comprehensive health care reform legislation this year. I appreciate the opportunity to testify today about 

the important role mammograms play in combating breast cancer 

deaths. 

As a medical oncologist who actually treats breast cancer patients, I have treated hundreds of breast cancer patients in my career. Indeed, I have observed firsthand the heartbreak this disease 

has on women and their families. Over the years I have also witnessed the advances we have made in breast cancer early detection 

and treatment, advances that 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, 30 to 40 percent of those who should be getting mammograms, from actually getting mammograms. I also have to note that 

in my own research published and cited before this committee before has shown that uninsured women of the same stage have poorer 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 recommendations 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 20 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 

useless 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 has 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 believes that screening mammography offers an identifiable 

and important survival benefit to women in the age group 40 to 49 

and indeed women age 40 and above. More specifically, the Society 

believes that the reduction 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 40. We do agree 

with the task force that women should be informed of the potential 

risks as well as the potential benefits of the procedure. 

The data and literature examined by the task force in the leadup to its November announcement on mammography is essentially 

the same data reviewed by an expert panel of breast cancer researchers, clinicians and epidemiologists convened by the American 

Cancer Society in 2003. However, in that earlier review 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 is a greater 

benefit to the mammography screening that does the task force. 


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In addition, since that time, a number of advancements have 

emerged that have shown to increase the effectiveness of mammography for women age 40 to 49. There have been improvements in 

the quality of mammograms resulting from the Mammography 

Quality Standards Act, or MQSA. There has been a shift to using 

digital mammograms over film mammograms, which research indicates may be more effective in screening younger women with 

denser breasts. The introduction of new technologies such as magnetic resonance imaging has also proven to be a particularly effective tool in high-risk women. 

Let me very clear on the next point. We understand 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 breasts 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 is a certain complacency or satisfaction with the use of mammography 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 there has been a lot of talk about breast selfexam, and as a medical oncologist and epidemiologist who is involved in screening and reads the screening literature and a doctor 

who treats, let me say that we have been talking past ourselves 

when we talk about breast self-exam today. Breast self-exam has 

shown in the medical literature and as spoken against by the task 

force is a woman doing a specific regimen and exam once a month. 

It actually would take about 20 to 30 minutes for a women to do. 

What most of us including the American Cancer Society have done 

is moved away from that regimented breast self-exam, which was 

advocated 20 to 30 years ago, toward something which is a little 

bit different, which is women being aware of their breasts and essentially 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-exam. There are two randomized clinical 

trials that show that breast awareness and breast self-exam are 

equivalent in terms of mortality reduction but breast self-exam actually increases the number of unnecessary biopsies done versus 

breast awareness, so I prefer to advocate breast awareness. 

I will note also that approximately 30 to 40 percent of American 

women age 40 and up are 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. 

In summing up, we know we can do better and with your help, 

Mr. Chairman, we are 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 and early detection by requiring first dollar 

coverage for prevention in both public and private plans with little 


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or no cost to patients. The Society and its affiliate, the American 

Cancer Society—— 

Mr. PALLONE. Doctor, I think you are concluding but I know you 

are 21⁄2 minutes over. 

Dr. BRAWLEY. I am sorry. We strong support the changes you 

have made in the legislation that will help the task force improve 

the transparency and inclusiveness of its operations. 

Let me just stop at that point and say thank you for asking me 

to appear here. 

[The prepared statement of Dr. Brawley follows:] 


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Mr. PALLONE. Thank you. 

Ms. Luray. 

STATEMENT OF JENNIFER LURAY 

Ms. LURAY. 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. Preventive Services Task 

Force. My name is Jennifer Luray and I am president of the Susan 

G. Komen for the Cure Advocacy Alliance, and on behalf of the patients, survivors, scientists, clinicians and advocates of the Komen 

family, we thank you for holding this hearing, and I also want to 

thank the previous task force witnesses for their honesty in 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 that mammography reduces the risk of dying from breast 

cancer, only debate over the timing and frequency of mammography. 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 risks and continue to follow existing screening recommendations including mammography beginning at age 40 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 are diagnosed before the age of 

50. This is a very typical one: ‘‘I was 46 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 II, and 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 is 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 

asked NIH to help us prepare by reporting on investments that 

they have made in screening technology. But let us also redouble 

our efforts on behalf of the one-third of women, some 23 million 

American women, who are not being screened due to lack of access, 

education or awareness. 

We partner closely with the CDC’s National Breast and Cervical 

Cancer Early Detection Program to fund free clinics and mobile 

vans yet the GAO found that over half of eligible women for this 

program do not receive screening. That is a disturbing finding that 

underscores the need for access to affordable insurance to eliminate 

health disparities. And that is why Komen supports the valuable 

patient protections in H.R. 3962 that would increase access to afVerDate Mar 15 2010 03:42 Sep 19, 2012 Jkt 074856 PO 00000 Frm 00107 Fmt 6633 Sfmt 6633 E:\HR\OC\A856.XXX A856

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fordable 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 40 to 49 will have access to the same 

coverage and cost-sharing benefits as women age 50 and older. 

Even a relatively small copayment reduces mammography rates. 

We do understand that H.R. 3962 will create a new entity which 

would not be bound by the task force’s guidelines and that the bill 

does not exclude from the minimum benefits package services that 

are not rated A and B, i.e., we understand that the task force recommendations are a floor, not a ceiling. But out bottom line is that 

women in the 40 to 49 age group may after consulting with their 

doctor choose to forego a mammogram but those who do choose to 

have one must have access to it on the same terms as women age 

50 and older. The Komen Advocacy Alliance is pleased that H.R. 

3962 includes patient representatives as advisors to the task force 

on clinical preventive 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 underserved women will be screened and that an intensive effort to make breakthroughs in screening technology will 

begin anew. Thank you, Mr. Chairman. 

[The prepared statement of Ms. Luray follows:] 


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Mr. PALLONE. Thank you. 

Dr. Sweet. 

STATEMENT OF DONNA SWEET 

Dr. SWEET. Good afternoon, and thank you, Chairman, for this 

opportunity. I am Donna Sweet, a general internist, and I am 

pleased to present the testimony of the American College of Physicians. I am a member of the ACP’s clinical efficacy assessment subcommittee, which oversees the development of ACP’s evidencebased guidelines, and I provide also comprehensive medical care to 

hundreds of patients in the State of Kansas. 

Because ACP does not comment on the guidelines issued by other 

organizations, I am unable to express an ACP opinion of the task 

force recommendations but I can speak to the College’s own guideline on screening mammography in women between ages 40 to 49 

years which was published actually in 2007. 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 base screening mammography decisions on 

benefits and harms of screening as well as a women’s preferences 

and her own breast cancer risk profile. The purpose of ACP’s 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 40 and 49 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 at menarche, and history of breast biopsy. In my own practice 

I use ACP’s guidelines to engage my female patients in a discussion. I explain that mammography, although a potentially valuable 

tool to screen for breast cancer, is an imperfect one. For some patients, I will detect cancer at a more treatable stage. It can also 

lead to false positives, which can lead to biopsies, scarring and potential infection. It can lead to 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 3 days, I have 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 66-year-old patient enrolled in 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 71-year-old came 

in and she wanted to get her mammogram, which was scheduled 

in February, before January 1st—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 disVerDate Mar 15 2010 03:42 Sep 19, 2012 Jkt 074856 PO 00000 Frm 00117 Fmt 6633 Sfmt 6633 E:\HR\OC\A856.XXX A856

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cussion, a 46-year-old women 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 yearly mammograms, that 

we did not do things from a cookie cutter. Women should not be 

treated all alike. And 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 gives 

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 and independent group of experts. 

Differences of opinion on the task force recommendations should be 

openly discussed but it is 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 stakeholder interest instead of by science. 

Second, the ACP is concerned that the public is misled by some 

into believing that cost was behind the task force recommendations. According to ARC, 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 a new constituted 

task force on clinical preventive services have given an A or a B. 

No limits are placed, 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 as 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 reviews 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 

shown 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 characteristics instead of being asked to 


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follow one-size-fits-all treatment protocols. And they have to know 

that the evidence comes from respected, independent and credible 

clinicians and other scientists protected from political and other 

stakeholder pressure. 

I thank you for this opportunity. 

[The prepared statement of Dr. Sweet follows:] 


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Mr. PALLONE. Thank you, Doctor. 

Ms. Visco. 

STATEMENT OF FRAN VISCO 

Ms. VISCO. Thank you. I am Fran Visco, president of the National Breast Cancer Coalition and a 22-year breast cancer survivor. 

As you know, NBCC 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 of scientific research. We analyze scientific 

information for our members and the public from the perspective 

of lay advocates. 

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 have 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 grass roots 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 has significant limitations and there has been much 

controversy over the years about screening programs: at what age 

are they effective, how do we balance risk and benefits, how can 

we communicate the very real limitations of screening and the 

harms associated with it. In 1997, an NIH consensus conference 

recommended against routine screening of women under the age of 

50, but political and outside organizational pushback, not evidence, 

torpedoed that recommendation. So in fact, we have known the 

issues with screening for decades. 

We also know that 40,000 women will die of breast cancer this 

year. Tens of millions of people in this country are uninsured. 

Many, many millions lack access to quality care. We know we have 

a great deal of work to do to fix this situation. We know that breast 

cancer is a complex disease, that while we have learned more about 

the biology of the disease, in the 4 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 looked carefully at updated evidence and objectively 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 have never had good evidence that this 


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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 caused 

some people to state over and over again that mammograms prevent breast cancer, and please, let us be very clear, mammograms 

do not prevent breast cancer. 

We had hoped that 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 is important also 

to put this in the context of a population where 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 devise a screening program that appropriately 

balances risks and benefits for these healthy women. 

So what did the task force actually say? To women in their 40s, 

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 decisions. On self-examination, Dr. Brawley pointed out that the self-examination touched on by the task force was 

that routine, regimented monthly search for cancer. It has been 

represented as saying that women shouldn’t know their bodies. Of 

course they should. This isn’t about that. 

Some are concerned that the new guidelines will prevent underserved 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 test that exposes 

women to radiation and the risks of false positives in order to get 

them to a doctor. Disadvantaged women deserve the same access 

as all other women to quality evidence-based care and the right information. We do need to 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 alleviate the unwarranted fear, not to feed it. Some argue that 

public health messages need to be simple and changing guidelines 

will confuse women. We would argue that while messages need to 

be simple, they need to be truthful. Women deserve the facts. 

We have all heard from women over the past month who are outraged and who believe that a mammogram saved their life. These 

anecdotes are not evidence. They may be compelling sound bites, 

great media stories but they are 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. Carolina Hinestrosa was the executive vice president of the National Breast Cancer Coalition, and 

her breast cancer was detected early in her late 30s, 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 


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so very careful about evidence and push for the right answers no 

matter how unhappy we are with what those answers are. Let us 

save our outrage for the reality that we know too little and women 

deserve so much more. Thank you. 

[The prepared statement of Ms. Visco follows:] 


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Mr. PALLONE. Thank you, and we will try to get this done before 

the votes. I don’t know if that is possible. I will start with myself. 

You know, I really want to apologize to you maybe on behalf of 

Congress, if I could that, because I was listening to what Dr. Sweet 

said, and you are absolutely right, that this has been totally politicized and I guess, you know, the problem is that Congress is political and maybe this isn’t the vehicle for it. I mean, it is sort of interesting to see that in the first panel most of the members were 

here and most of the media were here and now we are on the second panel, which is not the political panel, and the situation is reversed, you know. And Ms. Visco talked about how essentially— 

and I don’t want to put words in your mouth but, you know, after 

listening today, I can’t help but say I am not sure there really was 

that much of a difference between what the task force said now 

versus what the recommendation was a few years ago or even between what you are saying and the previous panel said. It is just 

amazing how these differences, if there are any, have been exaggerated and politicized. I guess that is just the nature of the process 

around here so I don’t know what we can do about it or make it 

any different, and I say that out of sadness, really. 

Let me ask you just a couple questions because I know the time 

is running out here. I will start with Dr. Brawley and also Ms. 

Luray. A few days after the task force 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 Komen echoed those concerns. But 

your statement, Dr. Brawley, listed a number of changes you would 

like to see in health reform and you discussed the importance of 

transparency and the task force’s process of arriving at its recommendations. Now, I believe that the bill H.R. 3962 actually addresses those concerns, so I wanted you to really, you know, answer that. I mean, the importance of stakeholder input and those 

recommendations you made about that, does the bill H.R. 3962 address those concerns? 

Dr. BRAWLEY. 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 in an open arena 

where people can actually see the process. 

Mr. PALLONE. And then Ms. Luray, from Komen’s perspective, do 

you agree that the provisions in H.R. 3962 would improve the task 

force recommendations process? I mean, you don’t have to just say 

yes or no, but go ahead. 

Ms. LURAY. Sir, actually yes. I mean, H.R. 3962 has a stakeholder panel that would advise the new clinical services task force 

and we think that makes a lot of sense. Such a panel I think could 

have helped to really communicate the findings of this task force, 

and even though people might not—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. 

Mr. PALLONE. I was just trying to make the point really that the 

issues that the American Cancer Society and Komen raised months 

ago well before these task force recommendations emerged, you 

know, that we felt on the House side we were listening to, and I 


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am trying to point out that as a result of your efforts and this collaboration 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 am going to ask all of you this 

quickly, and that is, as you know, my colleagues on the Republican 

side have repeatedly raised concerns about the House-passed 

health reform bill in light of the task force recommendations, and 

they have repeatedly asserted that H.R. 3962 somehow—well, I 

don’t want to put words in their mouth but I think there is a 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 on the whole, do you think the House-passed 

health reform bill, H.R. 3962, is actually more helpful, is a step forward or a step backward with regard to women with breast cancer 

and these screening issues? And I will just ask each of you to comment on that briefly. 

Dr. BRAWLEY. Mr. Chairman, if I can just say there are thousands of American women who die today because of lack of access. 

There are thousands of women who die today because they are detected early but they don’t have insurance to get access to reasonable and good care. Any effort that gets those people reasonable 

and good care is a good effort that is going to save lives. We have 

been talking about the number of lives that would be lost due to 

this recommendation of, maybe it was a recommendation not to get 

screened for women in their 40s, maybe it wasn’t, but the number 

of lives that we could just fix, that we could just save through a 

logistical fix is tremendous. Just get them access to care. 

Mr. PALLONE. Ms. Luray. 

Ms. LURAY. 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 asks that we followed very closely 

in health care reform, and those protections are included in H.R. 

3962. 

Mr. PALLONE. Thank you. 

Dr. Sweet. 

Dr. SWEET. Absolutely. This bill will help the health of American 

women with and without breast cancer. There are a number who 

do manage to get diagnosed and then have no access to reasonable 

care, as Dr. Brawley 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 insurability. They 

know if they leave their job and leave that health insurance, when 

they try to get the next one they are going to be uninsurable, and 

I think the fact that this bill addresses getting rid of preexisting 

conditions and guaranteeing health insurance to all at a 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 are going to give access to, and your bill does 

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force by improving payment and other things. So I think this bill 

is an absolute improvement. The millions of lives that we lose because of true lack of health insurance is much, much greater than 

what we are going to lose by a few women who decide not to have 

screening once they think about it. 

Mr. PALLONE. Thank you. 

Ms. Visco. 

Ms. VISCO. Well, as you know, Mr. Chairman, the National 

Breast Cancer Coalition has endorsed the House bill and we completely support it. We believe it is an 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 a 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 save lives, if we want to 

move forward, if we want to end breast cancer, we need guaranteed 

access to health care reform and the House bill is very important 

to achieving that end. 

Mr. PALLONE. Thank you. 

Let me mention, I was under the impression we had votes. In 

fact, we are in recess on the Floor so there is actually not any real 

time constraints here. 

Chairman Dingell. 

Mr. DINGELL. I want to thank the panel and congratulate them 

for their very fine presentation. I am going to begin by reading 

something which appeared, and you will recognize this, in the 

statement of Dr. Sweet. ‘‘Under Affordable Health Care for America Act, H.R. 3962, passed by the House of Representatives, a new 

task force on clinical preventive services would be created which 

would take on many of the responsibilities of the current U.S. Preventive Services Task Force. This new entity will have an important role in making evidence-based recognitions on preventive services that insurers would be required to cover but the only binding 

effect the recommendations of the task force will have on health 

plans is a requirement that preventive measures for which the task 

force has been given an A or B rating must be covered. The bill 

does not give the task force and the federal government itself any 

authority to put limits on coverage, ration care or require that insurers deny coverage. Health plans could offer additional preventive and other benefits of their choosing and no restrictions would 

be placed on their ability to consider recommendations from 

sources other than the task force in making such coverage recommendations. And now, if you please, starting with you, Dr. 

Brawley, do you agree with that statement? 

Dr. BRAWLEY. Well, sir, I am not a policy person, I am just a simple doctor. 

Mr. DINGELL. Well, just yes or no. 

Dr. BRAWLEY. But I do agree with your statement. 


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Mr. DINGELL. Thank you. I am not trying to lay traps here. I 

want that clear. 

Ms. Luray. 

Ms. LURAY. Yes, Congressman. As I said in my testimony, we 

also see the role of the task force as creating more of a floor than 

a ceiling, so in that sense, I would agree with you. 

Mr. DINGELL. Obviously, Dr. Sweet, you agree. 

Mr. SWEET. Yes, I do, and I have some very good policy people 

behind me that agree. That is important too. 

Mr. DINGELL. I am just trying to lay to rest some of the nasty 

untruths that are being circulated about this legislation. 

Ms. Visco. 

Ms. VISCO. Yes, I agree. 

Mr. DINGELL. Now, each of your organizations has supported the 

legislation, H.R. 3962. Do you have any apprehension that the provisions that we are discussing today or any other part of this legislation will trigger a nasty program of rationing health care? 

Dr. BRAWLEY. No, sir. 

Mr. DINGELL. Ma’am? 

Ms. LURAY. No, sir. 

Dr. SWEET. No. 

Mr. DINGELL. Ms. Visco? 

Ms. VISCO. No. 

Mr. DINGELL. Mr. Chair, I guess that is all the questions I have 

got. I think we have laid to rest some of the unfortunate misapprehensions of our colleagues and I can only express my great regret 

that they are not here to participate and to learn from the wisdom 

of our witnesses. Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you, Chairman Dingell. 

Mr. Green. 

Mr. GREEN. Thank you, Mr. Chairman. I apologize for being in 

and out but we have both Secretary Gates, Secretary Clinton and 

the Joint Chiefs of Staff and the Foreign Affairs Committee talking 

about Afghanistan, 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 to encourage women to see primary and preventive care services. We 

rely on our Harris County Hospital District and our communitybased health clinics to provide the services and screening for our 

constituents. I worry that the revised recommendations will discourage the safety-net providers from aggressively educating and 

screening for breast cancer in these underserved populations. I 

often say we have one of the premier medical centers in the world 

including M.D. Anderson Cancer Center located in our backyard 

but my constituents can see the medical center, it is just hard for 

them to get there because they are substantially uninsured. And 

unfortunately, most do not have the access to the medical services. 

Could you briefly speak about the current access barriers for breast 

cancer screening minority in those residing in medically underserved districts face and what impact these recommendations may 

have on these populations? Dr. Brawley? 

Dr. BRAWLEY. Well, Congressman, I hope the recommendations 

of the task force will have very little effect on your constituents 


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with the exception that perhaps the discussions that we have 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 40s and 50s who are diagnosed 

with breast cancer are actually diagnosed not through a traditional 

breast self-exam but through what we prefer to call breast awareness; they notice when they’re getting dressed or when they in the 

shower, that sort of thing. Perhaps people will hear this national 

conversation we have had and actually be a little bit freer to come 

forth and get evaluated by a doctor should they find an abnormality. I also hope that people will continue listening to the other 

organizations like the American Cancer Society that have said that 

women age 40 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 I will 

just leave you with one last statement. Mammography is imperfect 

but right now it is the best technical tool that we have other than 

awareness for early detection. 

Mr. GREEN. Mammography is much more valid than the PSA 

test is for males. 

Dr. BRAWLEY. Oh, yes, absolutely. You are absolutely correct. 

There are nine studies in the literature that show that mammography saves lives. There are two randomized trials on PSA, one 

that shows it saves lives and another that fails to confirm that first 

finding. 

Mr. GREEN. Ms. Luray. 

Ms. LURAY. Congressman, I would like to comment on that as 

well. As you know, we partner closely with the CDC and other providers to support free clinics and mobile vans in districts such as 

yours, and so we are very familiar with the kinds of constituents 

you have and really a very fragile relationship they have with the 

health care system, many of whom are uninsured, and so we have 

been working very hard in these last few weeks to make sure that 

the hullabaloo around the release of these recommendations 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 are working very hard to ensure that that message doesn’t get 

twisted around and be taken as a sign that mammography can’t 

provide help to them. 

Dr. SWEET. And I would hope as a 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 CNN or in the controversial position and maybe it 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 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 

as a critical time, and the hullabaloo, it is a political sort of system 

and there is a lot of things out there that just aren’t true, I think, 


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but it does bring women to discuss it, and once they bring it up, 

then the doctor, the clinician has to follow through. 

Mr. GREEN. Thank you. 

Ms. Visco. 

Ms. VISCO. Yes, we are working very, very hard on making certain that everyone in this country has guaranteed access to quality 

health care, and that will certainly solve the problem. We are 

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 underserved population, why do they not access the 

health care system, and of course, one of the reasons is, because 

they don’t have coverage for treatment. That is why the National 

Breast Cancer Coalition a number of years ago worked very hard 

to get enacted into law the CDC Breast and Cervical Cancer Treatment Act 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. 

Mr. GREEN. Thank you, Mr. Chairman. I know I am out of time. 

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. Chairman. 

Mr. PALLONE. Thank you, and I think that concludes our questions. I just want to thank all of you again. Once again, 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. 

Some of the members may submit written questions, and we try 

to get those to you within the next 10 days, so you might get some 

additional questions. Of course, the clerk would notify you of that 

and the time period to get back to us. But I do want to thank you 

again. 

Without objection, this meeting of the subcommittee is adjourned. Thanks. 

[Whereupon, at 3:05 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 


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