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Update to Breast Cancer Screening Guidelines Raises Concerns

Advocacy groups claim a recent draft of recommendations to update federal guidelines on women’s preventive health care failed to consider the diverse U.S. population and instead relied too heavily on data specifically on Caucasian women.

A key component of the new guidelines will affect the age at which insurance companies must cover the cost of women’s preventive breast cancer screenings, a controversial argument that dates back to before the 2010 health care overhaul.

Earlier this year, the Health Resources and Service Administration awarded the American Congress of Obstetricians and Gynecologists a five-year, nearly $1 million contract to spearhead the Women’s Preventive Surgery Initiative. The aim of the program is to outline ways to update the Women’s Preventive Services Guidelines, a set of medical services that insurers must cover without any cost to the patient.

ACOG released draft recommendations earlier this year and provided a 30-day comment period for outside groups to weigh in. Part of the proposal would reiterate a controversial recommendation that Congress has blocked since it was first put forward in 2009. That recommendation suggests that women in their 40s discuss with their doctor the “potential benefits and harms of screening,” but does not require insurers to cover the procedure. Breast cancer advocates believe insurers should cover mammography for women at this age.

ACOG hopes to send a final version to HRSA by the end of the year. But the speed at which ACOG is advancing the policy is raising red flags among some advocates.

“It’s too fast to really come out with something that is as meaningful as it should be,” Jane Delgado, president and chief executive officer of the National Alliance for Hispanic Health, said in a recent interview. “The way the process was designed was not a process which looked at making sure there was enough data by race [and] ethnicity to make valid conclusions about what should or should not be included.”

Delgado and others say by using aggregated clinical trial data to develop the recommendations, ACOG and its partners failed to account for populations typically not included in drug trials, like Latina, African-American or Asian-American women.

“No one has considered that maybe these guidelines shouldn’t be applied to all populations equally,” Linda Goler Blount, president and chief executive officer of the Black Women’s Health Imperative, told CQ Roll Call. “We’ve got to look at data and studies that actually include the women that are affected by these [diseases] most significantly.”

ACOG says the short comment period resulted from the need to send a final version to HRSA by Dec. 1.

“This wasn’t an arbitrary limit,” Christopher Zahn, vice president of practice activities at ACOG, said in an interview. “We felt very comfortable that we provided a process that was consistent with those used by other guideline-developing organizations.”

Critics took issue with the fact that ACOG did not hold any public forums on the draft, and set unusual stipulations around the protocol for submitting comments. Responses were limited to 1,000 characters, not words, a very restrictive amount, according to Blount.

“You are talking about broad guidelines which determine what insurers are going to pay for . . .  and you get 1,000 characters to comment on it,” Blount said.

Delgado, in an attempt to understand better the makeup of the steering committee that is working with ACOG to update the guidelines, requested from HRSA a list of individuals on the panel.

HRSA declined to release the names of the individual advisors, citing its confidentiality policy. While ACOG released a list of organizations represented on the panel that include the American Academy of Family Physicians and the American College of Physicians, Delgado and others argue that a list of individuals would show whether the committee included diverse perspectives.

“Practically everything in the recommendations was based on data on non-Hispanic white women,” Delgado said. “I appreciate how that is helpful to non-Hispanic white women, but you should not be applying that very same blunt instrument to everyone else.”

Zahn said the steering committee had a “broad range” of individuals representing different ages, races and ethnicities. He said any questions around the specific backgrounds of panel members are “inappropriate.”

A spokesperson for HRSA did not respond to requests for comments.

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