[Senate Report 105-158]
[From the U.S. Government Publishing Office]



                                                       Calendar No. 297
105th Congress                                                   Report
                                 SENATE

 1st Session                                                    105-158
_______________________________________________________________________


 
  AMENDING TITLE 38, UNITED STATES CODE, TO SPECIFY THE FREQUENCY OF 
 SCREENING MAMMOGRAMS PROVIDED TO WOMEN VETERANS BY THE DEPARTMENT OF 
                            VETERANS AFFAIRS

                                _______
                                

               November 13, 1997.--Ordered to be printed

_______________________________________________________________________


  Mr. Specter, from the Committee on Veterans' Affairs, submitted the 
                               following

                              R E P O R T

                         [To accompany S. 999]

    The Committee on Veterans' Affairs, to which was referred 
the bill (S. 999) to specify the frequency of screening 
mammograms provided to women veterans by the Department of 
Veterans Affairs, having considered the same, reports favorably 
thereon and recommends that the bill do pass.

                             Committee Bill

    The text of the bill as reported is as follows:

SECTION 1. FREQUENCY OF SCREENING MAMMOGRAMS.

    Section 106(a)(2) of the Veterans Health Care Act of 1992 (Public 
Law 102-585; 106 Stat. 4947; 38 U.S.C. 1710 note) is amended by 
striking out ``mammography.'' and inserting in lieu thereof 
``mammograms,'' with screening mammograms provided in accordance with 
the current recommendations of the American Cancer Society with respect 
to age of recipient and frequency of receipt.

                              Introduction

    On July 9, 1997, Committee Chairman Arlen Specter 
introduced S. 999, a bill to specify the frequency of screening 
mammograms provided to women veterans by the Department of 
Veterans Affairs.
    On July 25, 1997, the Committee held a hearing to receive 
testimony on S. 999 and on other bills pending before the 
Committee. The Committee received testimony from Senator Daniel 
K. Inouye, Senator Barbara Boxer, Representative Bob Filner, 
and Representative Benjamin A. Gilman, and received testimony 
for the record from Representative Sue W. Kelly. The Committee 
also received testimony from Stephen L. Lemons, Ed.D., VA's 
Acting Under Secretary for Benefits, Thomas L. Garthwaite, 
M.D., VA's Deputy Under Secretary for Health, and from 
representatives of The American Legion, Veterans of Foreign 
Wars, Disabled American Veterans, and Vietnam Veterans of 
America. Testimony was also submitted for the record of the 
hearing by the Office of Veterans Affairs, Philippine Embassy; 
Paralyzed Veterans of America; AMVETS; the American Coalition 
for Filipino Veterans; the Coordinating Council of Leaders of 
Veterans Organizations in Southern California; Filipino War 
Veterans, Incorporated; the National Coalition for Homeless 
Veterans; and LA Vets.
    Some of the witnesses expressed views on S. 999; some did 
not. Among those who expressed views on S. 999, there was an 
absence of consensus. The American Legion, Veterans of Foreign 
Wars, Disabled American Veterans, Paralyzed Veterans of 
America, AMVETS, and Vietnam Veterans of America expressed 
support for S. 999. VA opposed enactment of S. 999.

                           Committee Meeting

    After carefully reviewing the testimony from the July 25, 
1997, hearing, the Committee met in open session on October 7, 
1997, and voted by unanimous voice vote to report S. 999 
favorably to the Senate.

                               Discussion

                               background

    On April 22, 1997, the Department of Veterans Affairs (VA), 
Office of the Inspector General, issued a report titled, 
``Assessment of the Veterans Health Administration's Status in 
Providing Mammography Examinations.'' That report was critical 
of VA policies for providing mammography services to women 
veterans, noting, among other things, (1) that only 36 percent 
of women veterans treated in 1995 were offered mammograms; and 
(2) that the Inspector General could not determine whether VA 
consistently offered mammography services to eligible women 
veterans and, if so, whether such services were offered on a 
schedule recommended by the Department of Health and Human 
Services (HHS), the American Cancer Society (ACS), or some 
other medial authority. The Inspector General recommended that 
VA offer mammograms in accordance with ACS guidelines, which 
currently recommend yearly mammography screening for women 
patients beginning at age 40.
    VA's Under Secretary for Health responded to the Inspector 
General report by stating that VA policy provides for routine 
mammography screening for women between the ages of 50 and 69 
every 1 to 2 years, and that decisions to offer such services 
more frequently are made by individual clinicians in accordance 
with medical center, and Veterans Integrated Service Network, 
policy. At the Committee's hearing on July 25, 1997, VA's 
Deputy Under Secretary for Health, Dr. Thomas L. Garthwaite, 
articulated VA policy further, stating that VA's National 
Center for Health Promotion would recommend revisions in VA 
guidelines, as appropriate, within 6 months, but that ``we will 
only revise our policy on frequency of mammograms if, in our 
medical judgement, the evidence to date compels revision.''
    The Committee notes that breast cancer is the second 
leading cause of death among women, and that it is the leading 
cause of death among women between the ages of 40 and 49. The 
Committee notes, further, that an estimated 184,300 women were 
diagnosed with breast cancer in 1996, and, in 1997, an 
estimated 44,000 women will die from the disease. The Committee 
notes, finally, that research indicates that regular mammograms 
for women in their 40's can cut breast cancer mortality by 17 
percent.
    The American Cancer Society recommends annual mammography 
screening at age 40. The National Cancer Advisory Board and the 
National Cancer Institute recommend that women between 40 and 
49 years of age receive mammography screening every 1 to 2 
years. The American College of Radiology supports annual 
screening for women after the age of 40. Forty States either 
require insurance reimbursement for, or the mandatory provision 
of, routine mammogram screening of women between the ages of 40 
and 49.

                             committee bill

    The Committee bill would require VA to provide screening 
mammograms to women veterans who are eligible for care at VA 
treatment centers. Such mammography services would be offered 
in accordance with the current recommendations of the American 
Cancer Society, which recommends annual mammography screening 
beginning at age 40.

                             Cost Estimate

    In compliance with paragraph 11(a) of rule XXVI of the 
Standing Rules of the Senate, the Committee, based on 
information supplied by the Congressional Budget Office (CBO), 
estimates that, compared to the CBO baseline, there would be no 
costs or savings resulting from enactment of the Committee 
bill.
    The cost estimate provided by CBO follows:

                                     U.S. Congress,
                               Congressional Budget Office,
                                  Washington, DC, October 29, 1997.
Hon. Arlen Specter,
Chairman, Committee on Veterans' Affairs,
U.S. Senate, Washington, DC 20510.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 999, a bill to 
specify the frequency of screening mammograms provided to women 
veterans by the Department of Veterans Affairs.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Shawn Bishop.
            Sincerely,
                                         June E. O'Neill, Director.
    Enclosure.

    S. 999--A bill to specify the frequency of screening mammograms 
    provided to women veterans by the Department of Veterans Affairs

    Summary: Under current law, the Department of Veterans 
Affairs (VA) may provide mammography services to women 
veterans. As with other preventive measures, VA has developed 
guidelines for its primary care practitioners on the 
applicability and timeliness of mammography screening exams. 
VA's current guideline recommend that women veterans 50 years 
of age and over be provided with a mammography exam every two 
years.
    S. 999 would require VA to follow the mammography screening 
guidelines recently developed by the American Cancer Society, 
which recommend that women 40 years of age and over receive a 
mammogram every year. According to information from VA, its 
guidelines are currently under review by an internal committee 
in light of the new recommendations released by various 
organizations, including the American Cancer Society.
    CBO estimates that enactment of S. 999 would increase 
spending subject to appropriation by about $2 million a year. 
These costs would result from about 20,000 additional 
mammograms a year, assuming that most women between the ages of 
50 and 69 who currently get mammograms from VA every two years 
would get them annually, and that women veterans between the 
ages of 40 and 49 would receive mammograms from VA at about the 
same rate as those between the ages of 50 and 69 under the new 
guidelines. The bill may have no net budgetary impact if VA's 
internal review leads it to adopt the American Cancer Society's 
guidelines without legislative action.
    Because the bill would not affect direct spending or 
receipts, pay-as-you-go procedures would not apply. The bill 
contains no intergovernmental or private-sector mandates as 
defined in the Unfunded Mandates Reform Act and would not 
affect the budgets of state, local, or tribal governments.
    The estimate was prepared by Shawn Bishop, who can be 
reached at 226-2840. The estimate was approved by Robert A. 
Sunshine, Deputy Assistant Director for Budget Analysis.

                      Regulatory Impact Statement

    In compliance with paragraph 11(b) of rule XXVI of the 
Standing Rules of the Senate, the Committee on Veterans' 
Affairs has made an evaluation of the regulatory impact that 
would be incurred in carrying out the Committee bill. The 
Committee finds that the Committee bill would not entail any 
regulation of individuals or businesses or result in any impact 
on the personal privacy of any individuals, and that the 
paperwork resulting from enactment would be minimal.

                 Tabulation of Votes Cast in Committee

    In compliance with paragraph 7 of rule XXVI of the Standing 
Rules of the Senate, the following is a tabulation of votes 
cast in person or by proxy by members of the Committee on 
Veterans' Affairs at its October 7, 1997, meeting. On that 
date, the Committee, by unanimous voice vote, ordered S. 999, 
as amended, reported favorably to the Senate.

                             Agency Report

    On July 25, 1997, Thomas L. Garthwaite, M.D., Deputy Under 
Secretary for Health, Department of Veterans Affairs, submitted 
testimony on, among other things, S. 999. An excerpt from that 
testimony is reprinted below:

  Statement of Thomas L. Garthwaite, M.D., Deputy Under Secretary for 
                 Health, Department of Veterans Affairs

    Mr. Chairman and Members:
    I am pleased to be here to discuss the array of bills being 
considered by the Committee. Included is S. 801, a bill that 
would make changes in procedures for resolving complaints of 
employment discrimination and sexual harassment, S. 999, a bill 
pertaining to setting standards for how frequently we should 
offer mammograms to women veterans, and a draft bill that would 
change our health care resource allocation system. You also 
asked that we comment on a bill making technical amendments to 
the eligibility legislation enacted last year, a bill extending 
a number of expiring authorities, a draft bill containing 
authorizations for constructions projects, and finally, S. 309, 
a bill pertaining to parking fees at a VA facility in Hawaii.
          * * * * * * *


                      s. 999--mammogram screenings


    S. 999 would require the Department to provide mammograms 
to women veterans at the age and rate currently recommended by 
the American Cancer Society. We strongly oppose this bill.
    The issue of mammogram screenings for women between the age 
of 40 and 49 rose to the forefront in January of 1997 when the 
National Institutes of Health Consensus Conference agreed with 
other experts (including the U.S. Preventive Services Task 
Force, The American College of Physicians, and the Canadian 
Task Force on the Periodic Health Examination) that there was 
no strong evidence on which to base a recommendation that women 
agreed 40 to 49 have routine mammograms. The Director of the 
National Cancer Institute Subsequently convened a National 
Cancer Advisory Board to review the evidence. This board 
concluded that the evidence supported recommending that women 
in this age group have routine mammograms, i.e., every one or 
two years.
    It is not uncommon for scientific and medical experts to 
reach differing conclusions based on their interpretations of 
the same evidence. At best, one can say that the question of 
whether women in this age bracket should receive annual or bi-
annual mammograms is still being debated and is far from 
decided. It will take time for a consensus on this matter to 
develop in the relevant medical and scientific communities. 
Consequently, the American Cancer Society's recommendation 
cannot be said to establish the accepted national clinical 
standard on frequency of mammograms for this age group. 
Moreover, the American Cancer Society is not recognized by many 
experts as the entity able to alone establish such a standard.
    As for VA's position in this debate, we are considering our 
policy on frequency of mammograms in light of this controversy. 
VA's current clinical guidelines on mammograms were issued 
before the controversy occurred in January of 1997; they 
recommend mammograms for women from age 50 to 69. However, in 
light of this controversy, our National Center for Health 
Promotion has been directed to study this issue and to revise, 
if and as appropriate, VA's guidelines for mammography in VA 
facilities. New mammography guidelines should be in place in 
six months. However, we underscore that we will only revise our 
policy on frequency of mammograms if, in our medical judgment, 
the evidence to date compels a revision. In the interim, we are 
confident that women veterans in this age bracket are receiving 
adequate mammography screenings. A direct inquiry of women 
veterans performed by the Center for Health Promotion recently 
revealed that 75% of women veterans between the ages of 40 and 
49 reported receiving a mammogram within the past two years.
    Clinical standards should not be established by statute. 
Such standards are, by their nature, ever changing. As medical 
knowledge advances, clinical treatments and standards are 
revised as necessary. In some cases, they are changed or 
replaced completely by a more suitable treatment protocol. Even 
when clinical standards are recognized and accepted by the 
medical profession, they must still be adapted to every 
individual patient's clinical needs. It is crucial these 
standards be flexible. For that reason, they must serve more as 
``guidelines'' than rules for the practitioner.

          Changes in Existing Law Made by S. 464, as Reported

    In compliance with paragraph 12 of Rule XXVI of the 
Standing Rules of the Senate, changes in existing law made by 
the Committee bill, as reported, are shown as follows ( 
existing law proposed to be omitted is enclosed in black 
brackets, new matter is printed in italic, existing law in 
which no change is proposed is shown in roman):

                    VETERANS HEALTH CARE ACT OF 1992

           * * * * * * *

                TITLE I--WOMEN VETERANS HEALTH PROGRAMS

           * * * * * * *

SEC. 106. HEALTH CARE SERVICES FOR WOMEN.

    (a) General Authority.--In furnishing hospital care and 
medical services under chapter 17 of title 38, United States 
Code, the Secretary of Veterans Affairs may provide to women 
the following health care services:
    (a) * * *
    (2) Breast examinations and [mammography.] mammograms, with 
screening mammograms provided in accordance with the current 
recommendations of the American Cancer Society with respect to 
age of recipient and frequency of receipt.
           * * * * * * *