The American College of Physicians has weighed-in the media flap over evidence-based medical recommendations . ACP's for them. So are we. We have no expertise in the area of mammography, but we are close students of the larger question over whether "evidence" or "experts" should be the source of our public health policies. We weigh-in on the side of evidence-based recommendations.

ACP president Joseph W. Stubbs decries "the politicization of evidence-based clinical research." He calls for reliance on evidence and a transparent process. Noble words, we'd agree.

But inconsistent. ACP still carries on its website, a 2004 advisory to ignore the 2003 findings of this same US Preventive Services Task Force ; USPSTF found insufficient evidence to support a population salt-reduction strategy . We agree with that evidence-based conclusion as well and invite Dr. Stubbs to join us in advocating a "constructive and transparent" process on the salt/health controversy.

With that single caveat, we commend the ACP statement that

... critics have made unfair and unsubstantiated attacks on the expertise, motivations, and independence of the scientists and clinician experts on the USPSTF.

ACP believes that it is essential that clinicians and patients be able to make their own decisions on diagnosis and treatment informed by the best available scientific evidence on the effectiveness of different treatments and diagnostic interventions. The USPSTF is a highly regarded, credible and independent group of experts that performs this role, on a purely advisory basis, to the Department of Health and Human Services, as it relates to interventions to prevent or detect diseases. As is often the case with evidence-based reviews, the USPTF’s recommendations will not always be consistent with the guidelines established by other experts in the field, by professional medical societies, and by patient advocacy groups. Such differences of opinion, expressed in a constructive and transparent manner so that patients and their clinicians can make their own best judgment, are important and welcome. It is not constructive to make ill-founded attacks on the integrity, credibility, motivations, and expertise of the clinicians and scientists on the USPSTF.

Some critics have erroneously charged that the USPSTF’s recommendations were motivated by a desire to control costs. According to the Agency for Health Care Research and Quality, “the USPSTF does not consider economic costs in making recommendations.” The Agency continues, “it realizes that these costs are important in the decision to implement preventive services. Thus, in situations where there is likely to be some effectiveness of the service, the Task Force searches for evidence of the costs and cost-effectiveness of implementation, presenting this information separately from its recommendation” and the “recommendations are not modified to accommodate concerns about insurance coverage of preventive services, medicolegal liability, or legislation, but users of the recommendations may need to do so.” [emphasis added in bold]

Under the bills being considered by Congress, the USPSTF will have an important role in making evidence-based recommendations on preventive services that insurers will be required to cover, but the bills do not give the Task Force — or the federal government itself — any authority to put limitations on coverage, ration care, or require that insurers deny coverage. Specifically, the House and Senate bills would require health plans to cover preventive services based in large part on the evidence-based reviews by the USPSTF, but no limits are placed on health plans’ ability to offer additional preventive benefits, or in considering advice from sources other than the USPSTF in making such coverage determinations. Accordingly, patients will benefit by having a floor – not a limit – on essential preventive services that would be covered by all health insurers, usually with no out-of-pocket cost to them. Patients will also benefit from having independent research on the comparative effectiveness of different treatments, as proposed in the bills before Congress. The bills specifically prohibit use of comparative effectiveness research to limit coverage or deny care based on cost.

The controversy over the mammography guidelines illustrates the importance of communicating information on evidence-based reviews to the public in a way that facilitates an understanding of how such reviews are conducted and how they are intended to support, not supplant, individual decision-making by patients and their clinicians.

ACP urges Congress, the administration, and patient and physician advocacy groups to respect and support the importance of protecting evidence-based research by respected scientists and clinicians from being used to score political points that do not serve the public’s interest.

Let's all agree on the process: follow the science. And then let's agree that digging in to defend the current politically-correct policies -- whatever they may be, but in our area of concern, policies that try to guide salt intake levels -- should be seriously questioned when such independent policy auditors as the USPSTF point out discrepancies between policy and evidence. To paraphrase the strategy that unraveled the Watergate scandal: follow the evidence. Let's not cherry-pick the science and support only the outcomes we like.

As we blogged when we first learned of the U.S. Preventive Services Task Force's revised recommendations on frequency of mammograms , we wished USPSTF were as influential as media coverage suggested -- and not because we wanted to express an opinion on this recommendation. Rather, we wanted to endorse the process of evidence-based public health policy.

That was two or three forests worth of coverage ago, and most of the media accounts studiously avoid the real question: is there evidence to support the recommendation? Story after story deal with the outrage on the left about damage to women's empowerment or, conversely, on the right, questions about whether the reduced use of the procedure presages the rationing of medical care alleged integral to ObamaCare.

Dr. Gilbert Ross of the American Council for Science and Health has a healthier perspective.

“I don't think this issue is a gender-related one at all,” says Dr. Ross. “It certainly shouldn't be. Actually, the emerging recommendations for PSA screening for prostate cancer are very similar to these breast cancer recommendations. The authoritative bodies weighing in on PSA screening basically say don't do it unless there is some rationale for it in terms of specific risk factors, because the potential downsides outweigh the benefits. Of course, any kind of cancer screening is always an emotional issue. For women who want a more individualized risk estimate to help guide them in this decision, the NCI has a 'tool' for figuring out one's risk for breast cancer. Some women in a higher-risk category, besides getting more frequent mammograms, may also consider discussing with their doctors the potential benefits of taking a drug to reduce risk of breast cancer -- chemoprevention.

...“We believe that politicizing this issue does no one any good and contributes to confusion among women and their doctors,” says Dr. Ross. “In fact, this is an unusual instance when we agree with a New York Times editorial, calling for the mammography screening discussion to be completely severed from the ongoing healthcare reform debate.”

ACSH quotes Dr. Arthur Caplan,director of the Center for Bioethics at the University of Pennsylvania, added his weight to the argument for reason:

“In this case, the taskforce found that screening all women in their forties led to too many false positives and too much unnecessary follow-up testing for the number of lives it saved. They did not say that no lives were being saved. They said not as many as everyone thought. And not enough to justify asking every woman under fifty to get a mammogram every year...

“There is no reason to doubt the accuracy of the scientists' finding that evidence does not support routine mammography for most women under fifty. But there is every reason to doubt that the numbers they compiled will be sufficient to overturn a medical practice that carries so much ethical weight for women.”

Let's not get hung up on how we feel on this issue. Science is evolutionary. Evidence can improve over time. Let's follow the science, not the ideologues.

It has been but a few short days since the U.S. media heralded findings by the U.S. Preventive Service Task Force (USPSTF) that there is insufficient evidence to recommend that some women get regular mammograms. The press reported that the USPSTF is "influential" in setting federal policy. We responded that we only hoped it was true , but, sadly, that hadn't been our experience. The USPSTF has been a lonely voice insisting on quality science to guide policy.

We know nothing of the quality of the science on either side of the mammogram debate, but we do know that when the evidence-based recommendations of the USPSTF come up against political correctness, PC politics wins. That's been the case with the debate over dietary salt.

Thus, it was no surprise that the White House ducked. The NY Times reported that when "the task force recommendations stirred concern among women, and came under fire from lawmakers of both parties, the White House emphasized that they were not binding...."

That's the way the federal government has dealt with the salt debate: politics trumped science. The USPSTF found insufficient evidence to recommend a general reduction in salt intakes, but the powers-that-be blithely ignored this evidence-based conclusion and redoubled its efforts to achieve the impossible: substituting federal recommendations for human physiology. Read all about it .

"(E)xcessive salt restriction is as harmful as high salt in heart failure," concludes a study in the European Journal of Pharmacology . The Osaka, Japan-based research team demonstrated that for heart failure patients low-salt diets activate plasma aldosterone and the "increased plasma aldosterone level with strict salt restriction activated the mineralocorticoid receptor signaling in volume-overloaded condition, resulting in increased myocardial fibrosis."

In short, yet another study showing the risk of low-salt diets. The authors conclude:

A recent report showed that high sodium intake rather improved cardiac performance, induced peripheral vasodilatation, and suppressed the release of vasoconstrictor hormones in patients with compensated heart failure (Damgaard et al., 2006). Indeed, our findings suggest that salt depletion, which increases the plasma aldosterone level, must be avoided in addition to salt overload in the treatment of heart failure.

There was an interesting story on the front page in the print edition of today's Wall Street Journal with an eye-catching but gratuitously offensive and grossly inaccurate headline: "Maybe Mummy Should Have Laid Off the Salt." We had to respond :

There has been exactly one clinical trial of the effect of low-salt diets on cardiovascular morality and rehospitalization for congestive heart failure. That study confirmed observational studies and showed conclusively that low salt diets produced greater mortality. See the article in Clinical Science, "Normal-sodium diet compared with low-sodium diet in compensated congestive heart failure: is sodium an old enemy or a new friend? " It concludes: "The results of the present study show that a normal-sodium diet improves outcome, and sodiumdepletion has detrimental renal and neurohormonal effects with worse clinical outcome...."

So, perhaps the mummy should have used more salt during life -- as well as the salts used in the mummification process.

It's headline writers like this that are responsible for newspapers coming in dead last in terms of consumer confidence .

TheWashington Post just released a story that the U.S. Preventive Services Task Force has concluded that mammograms are unwise for younger women. Post reporter Rob Stein describes the USPSTF as "an influential federal task force" and "the federal panel that sets government policy on prevention."

We could only hope that his description was true. In fact, the USPSTF has been trying to steer the federal government away from "junk science" and towards "evidence-based" health interventions for years. This may be, as Stein sums up, a "radical change" in public health recommendations.

Perhaps now people will pay more attention to what the USPSTF concluded back in 2003 and maintains today: our present policy discouraging salt intake in the general population may be politically-correct, but it is a scientifically-flawed policy. The USPSTF has studied the question and found insufficient evidence to make a general recommendation for the public .

We'd all be better off if the US Prevention Services Task force was, indeed, the influential panel that sets government policy on prevention that the Post postulates.