The Mammogram Diversion: Is Komen Laying the Groundwork to Reject Planned Parenthood Proposals?

Is the Susan G. Komen Foundation using a “mammogram diversion” as a precursor to denying Planned Parenthood state affiliates access to future grants for breast cancer education and screening?

Komen's ostensible new strategy, to focus its prevention grants “only on mammograms,” would not only exclude Planned Parenthood clinics from eligibility, but would also deny tens of thousands of low-income and uninsured women medically-indicated primary preventive breast health services and, potentially, leave many with undiagnosed breast cancers. This at a time when there is an urgent need among low-income and underserved women—those served by Planned Parenthood—for greater access to primary preventive care. Yet even despite the lack of medical evidence for the strategy, the far right anti-choice publicity machine went into high gear over the weekend in what seemed like a pre-emptive strike in support of it.

Last week, Komen created a firestorm when it said that Planned Parenthood affiliates would be prohibited from applying for the breast cancer education and screening funds they had been getting for five years. The first of what turned out to be a changing list of reasons was “a new policy” denying funding to any organization “under investigation” and specifically pointing to Planned Parenthood, which is the target of any number of witch hunts but no actual investigations. (Curiously, the new policy did not, apparently, apply to Penn State University, which is under actual criminal investigation, nor to a long list of universities and corporations in which researchers and others are under investigation and to which Komen money continues to flow.) Komen executives and board members at first vociferously denied the move was political, but they've now been caught out by emails provided to Laura Bassett of the Huffington Post which make clear that Karen Handel, Komen's anti-choice Senior Vice President of Policy, was the architect of the new policy, and by reports that former Bush spokesman Ari Fleischer also was involved. Moreover, Jane Abraham, General Chair of the virulently anti-choice Susan B. Anthony List continues to sit on Komen's advocacy board right there alongside Komen Chief Executive Officer Ambassador Nancy Brinker.

Then came Part Two. As the backlash against the “investigation exception” grew out of control, Brinker came out with another reason that their grant criteria were changing: They want to focus directly on mammograms.

During Komen's damage-control press conference, for example, Brinker told reporters:

“We have decided not to fund, wherever possible, pass-through grants. We were giving them [Planned Parenthood] money, they were sending women out for mammograms. What we would like to have are clinics where we can directly fund mammograms.”

She further stated:

“We look at the quality of the grants,” Brinker said. “We don't like to do pass-through grants anymore.”

Pass-through? Is an OB/GYN or a primary care provider such as an internist a “pass-through?” Or are they part of the continuum of care? Because except in highly unusual circumstances, women don't generally walk into a radiology clinic for a mammogram without having first seen and obtained an order for a mammogram from a primary care provider. In some states, such as Maryland, low-income women cannot get a state-subsidized mammogram without first going to, being examined by, and getting an order for a mammogram from a licensed primary care provider.

Mammograms are only one part of comprehensive breast health strategies that begin with breast health education and self-awareness, collection of personal medical histories and risk factors, and conducting clinical breast exams. So is Komen trying to prevent and catch the greatest number of breast cancers at the earliest possible stages, or is it using mammograms as a foil for de-funding Planned Parenthood?

Until a few years ago, women were constantly told to conduct monthly self-examinations and, unless we discovered something in between appointments, to have our breasts checked annually by our primary care doctors. We were also told to get annual mammograms starting at age 40.

Now, however, that has changed. Public health bodies such as the United States Preventive Services Task Force (USPSTF) and the American College of Obstetricians and Gynecologists (ACOG) have reviewed the evidence on breast cancer prevention strategies, and have arrived at different conclusions. As a result, recommendations for breast cancer prevention are now in flux, and in fact are somewhat controversial.

Nonetheless, none of the new recommendations support Komen's new strategy.

Guidelines released in 2009 by the USPSTF, for example, suggest that evidence does not support the efficacy of breast self-exams. They also state that only women ages 50 and older should be getting mammograms, and then only every other year until they are between the ages of 70 and 75 years. By contrast, ACOG, the American Cancer Society (ACA), the National Cancer Institute (NCI), and the National Comprehensive Cancer Network (NCCN) all still recommend mammograms for women ages 40 and over either every year or every other year.

The differences in mammography recommendations lie in part in the emphasis put on risk-benefit calculations. Mammograms involve radiation and therefore carry risk. The USPSTF based its recommendations in part on the fact that the majority of breast cancers occur in women age 50 and older and the fact that repeated mammograms expose women to additional radiation which itself is a risk factor for cancer. The others maintain that the risk is worth it for finding cancers in younger women which, though fewer in overall numbers, according to ACOG, have a lesser “sojourn time,” or the time in which it takes the cancer to grow and spread.

But again, mammograms are only part of the equation. All of these groups recommend clinical breast exams conducted by primary care givers at varying intervals. But none except NCCN still recommend monthly breast self-exams as a primary preventive practice, suggesting instead that primary providers work with patients to increase “breast self-awareness.”

An ACOG breast health bulletin, for example, states:

Breast self-examination is the performance of an examination of the breasts in a consistent, systematic way by the individual on a regular basis, typically monthly. Historically, physicians have been encouraged to educate their patients on how to perform these examinations, and public awareness campaigns have focused on this intervention. It still may be appropriate for certain high-risk populations and for other women who choose to follow this approach

Currently, there is an evolution away from teaching breast self-examination toward the concept of breast self-awareness. The College, the American Cancer Society, and the National Comprehensive Cancer Network endorse breast self-awareness, which is defined as women’s aware-ness of the normal appearance and feel of their breasts. This concept has arisen because approximately one half of all cases of breast cancer in women 50 years and older and more than 70 percent of cases of cancer in women younger than 50 years are detected by women themselves, frequently as an incidental finding (29, 30). In addition, the effectiveness of self-examination was at odds with what was anticipated based on the aforementioned statistics.

Breast self-awareness should be encouraged and can include breast self-examination. Women who desire to perform self-examination as a part of this breast self-screen awareness strategy may be instructed in the appropriate technique, although emphasis is not on examination techniques. Women should report any changes in their breasts to their health care providers. Although this patient education strategy has not been studied to date, breast awareness may be of particular importance as part of a screening strategy because some women may falsely assume that negative mammography or clinical breast examination results definitively exclude the presence of breast cancer. New cases of cancer can arise during screening intervals, and breast self-awareness may prompt women not to delay in reporting breast changes based on false reassurance of recent negative screening result. Breast self-awareness aims to capture the importance of self-detection and prompt evaluation of symptoms because it relates to overall breast cancer morbidity and mortality. However, the effect of breast self-awareness education has not been studied.

The bottom line in all of this is that recommended breast cancer prevention practices now are based on increased not reduced connection and communication with a primary care provider of the kind Planned Parenthood represents to its clients.

Even the radiologists on Komen's board agree: Dr. Kathy Plesser, a New York City radiologist and member of Komen’s scientific advisory board, said she would resign if Komen did not reverse its decision, according to the New York Times.

“I strongly believe women need access to care, particularly underserved women,” Dr. Plesser said. “My understanding is that by eliminating this funding, it will jeopardize the women served by Planned Parenthood in terms of breast care.”

And if the focus is on “outcomes,” Planned Parenthood clinics have proven they use their funds effectively. From a report by John Tomasic:

According to numbers made public by Komen this week, Komen gave Planned Parenthood of the Rocky Mountains $125,000 last year, or 4.3 percent of the nearly $3 million Komen spent fighting breast cancer. Yet Planned Parenthood clinics here detected nearly 20 percent of all of the cases of breast cancer discovered through Denver Komen spending, which supports roughly 40 organizations operating clinics, shelters, hospices, research facilities and so on mostly across the northern Front Range but also in Summit, Park and Douglas Counties.

In fact, just last year, Brinker herself strongly lauded Planned Parenthood and underscored the importance of Komen's relationship with them for all of the reasons above.

Nonetheless, Komen's new mammogram theme suggests that “Plan B” for the Foundation and the anti-choice community for denying future funds to Planned Parenthood's clinical breast health education and clinical care programs may be “the mammogram diversion.”

The indication that something more than a foundation reconsidering its guidelines was going on came this past weekend, when the anti-choice community, which never lets medical and public health evidence get in the way of a good ideological crusade, began chanting “they don't do mammograms” with the precision of a well-crafted and coordinated far-right talking-point campaign.

For example, almost immediately as Komen's press conference was over, the good soldiers of the anti-choice army such as the Washington Post's Kathleen Parker immediately began deploying the mammogram diversion. Parker wrote:

To recap: Komen created a firestorm with its recent decision to stop donating about $680,000 a year to Planned Parenthood. (On Friday, Komen released a statement noting that Planned Parenthood will be eligible for future grants, although they won’t be guaranteed.) The bulk of that money was supposed to be used for breast cancer screening. Most Planned Parenthood affiliates don’t do mammograms but refer women elsewhere, sometimes reimbursing them using Komen funds.

George Will and Dana Loesch joined the fray on ABC's “This Week” with George Stephanopoulos, where both complained that Planned Parenthood does not do mammograms. Loesch said:

Now, you would think at some point in the past — it's been a year to the date since Live Action called Planned Parenthood clinics in 27 different states to ask whether or not they had mammography machines. You would think that at that point — they'd had a year — Planned Parenthood would invest in obtaining licenses to operate and own mammography machines and give mammograms so they could have avoided this whole thing.

And Will stated:

This is not about women's health. This is about providing 300,000 abortions a year. They — Planned Parenthood cleverly cast this to say we are in the mammogram business. They're not in the mammogram business. They're in the referral of mammograms.

Planned Parenthood Federation of America has never said it does mammograms. Planned Parenthood clinics do, however, serve as a gateway to mammograms when they are needed, just as your OB/GYN or internist would do. But first it also does what any good medical provider does: a family history, an exam, breast health education, clinical examination and the like, all the while offering other primary care, ranging from diabetes and blood pressure screening to Pap smears and contraceptive delivery. In short, Planned Parenthood clinics provide the same services to women as does a private OB/GYN, the difference being that for the low-income, uninsured or under-insured women Planned Parenthood is their OB/GYN and primary care provider.

We can perhaps expect the staunchly anti-choice George Will—who is obviously not a woman though he likes to speak for them—to mislead people with this deliberately mis-informed Lila-Rose nonsense. But surely Dana Loesch has at some point in her life turned to an OB/GYN (and Dana, if you haven't, go get a check up!). And surely having done so must have undergone a breast exam and discussion with her primary care provider at some point, or at least is aware these happen? Or is she so far out in right field she knowingly lies for the sake of being part of the anti-choice old-boys club?

There are good reasons Planned Parenthood does not do mammograms and good reasons why Komen should continue funding them nonetheless. Planned Parenthood refers and has always referred for mammograms because that is what primary care providers do. Mammograms are a specialized intervention done and evaluated by radiologists trained to conduct and read them. Planned Parenthood doesn't do them for the same reason your OB/GYN doesn't do them. They are part of a continuum of care in which different actors play different roles.

Yet it is a theme the right has been beating so forcefully the past several days it can't be called anything but a coordinated campaign. The low-income, uninsured and under-insured women who come to Planned Parenthood for basic reproductive health care and gynecological exams do so because Planned Parenthood doctors and nurses are their OB/GYNs and primary care providers.

If Komen suddenly decides it is no longer about comprehensive breast cancer prevention services, it will be deciding as well to abandon those low-income and uninsured women whose primary care its grants were helping to support. And it will underscore that the anti-choice community—and now Komen with it—are less concerned about the health and rights of real women in need than they are about ideology and politics. It will also be acting in the interest of reducing rather than increasing access to the low-income, uninsured and under-insured women of color who die at higher rates from breast cancer in large part because they lack access to such routine primary preventive care. As a breast cancer foundation, one would think Komen would be pouring more, not less, money into groups like Planned Parenthood.

From what I've seen, the vast majority of those millions of women and men whose own money make up the resources of the Susan G. Komen Foundation—the racers, walkers, neighborhood fund-raisers, and buyers of “pink” products—are more interested in saving people's lives.