EXECUTIVE SUMMARY
A new research letter contains in-depth information about breast cancer screening recommendations physicians give their patients amid recent guideline changes.
- More than 80% of physicians recommended screening to women ages 40-44; 88% to women ages 45-49; and 67% for women 75 years of age or older, the data indicate.
- The American Cancer Society calls for personalized screening decisions for women ages 40-44, followed by annual screening starting at age 45 and biennial screening for women 55 years of age or older. The U.S. Preventive Services Task Force recommends personalized screening decisions for women ages 40-49, followed by biennial mammograms for women ages 50-74.
When it comes to the best time to start and discontinue mammography for breast cancer screening, as well as the optimal amount of time between screenings, clashes remain in recommendations from professional societies and organizations.
A recently published research letter contains in-depth information about breast cancer screening recommendations physicians give their patients amid recent guideline changes.
In 2015, the American Cancer Society (ACS) called for personalized screening decisions for women 40-44 years of age, followed by annual screening starting at age 45 and biennial screening for women 55 years of age or older.2 The U.S. Preventive Services Task Force (USPSTF) reissued its guidance in 2016, calling for personalized screening decisions for women 40-49 years of age, followed by biennial mammograms for women 50-74 years of age.3 The American College of Obstetricians and Gynecologists (ACOG) calls for yearly mammograms for women 40 years of age and older.4 (In the January 2016 issue of Contraceptive Technology Update, we reported on the ACS and USPSTF recommendations [http://bit.ly/2p6Ybpw]. Further information is available in the April 2016 issue [http://bit.ly/2p6IH50].)
Archana Radhakrishnan, MD, MHS, a fellow in the division of general internal medicine at Johns Hopkins University, and coauthors studied physician screening recommendations in a national sample of physicians. The survey received a 52% response rate among eligible participants, with 871 of 1,665 physicians issuing a response. About half of the clinicians were family medicine/general practice physicians, with about 30% identifying as internal medicine physicians and 26.1% as gynecologists.
More than 80% of physicians recommended screening to women ages 40-44; 88% to women ages 45-49; and 67% for women 75 years of age or older. Data indicate gynecologists were more likely to recommend screening for women of all ages compared with internal medicine and family medicine/general practice physicians. Among those who recommend screening, most indicated annual examinations. About 25% said they trusted ACOG guidelines the most, while 23.8% followed the ACS guidance, and 22.9% said they followed USPSTF recommendations.1
What’s Your Move?
In an accompanying editorial, University of California, San Francisco School of Medicine professors Deborah Grady, MD, MPH, and Rita Redberg, MD, MSc, noted that the findings from the recent survey are “dispiriting” because they indicate that a large proportion of primary care physicians recommend screening mammography for women who are more likely to experience harms than benefits from the examination.5
“Owing to the greater chance of harm, neither the American Cancer Society nor the U.S. Preventive Services Task Force recommend routine screening mammography for women ages 40 to 44 years,” Grady and Redberg wrote. “Despite this, 81% of the primary care physicians surveyed in this study reported that they recommend mammography to women in this age range.”
Results of a 2014 study indicated that annual mammography in women 40-59 years of age did not reduce mortality from breast cancer beyond that of physical exam or usual care when adjuvant therapy for breast cancer is freely available.6 The 2014 analysis showed 1,190 breast cancer diagnoses; 666 occurred in women who underwent mammograms and 524 in the control group. However, after 25 years, nearly the same number of women in each group died from the disease. The analysis also indicated that 22% of invasive breast cancers detected by screening were overdiagnosed, causing women to undergo unnecessary procedures for cancers that were slow to develop or did not require any treatment.6
“I think that clinicians need to periodically use breast cancer risk calculators available online to assess the near-term and lifelong probability that each of their patients faces for developing that cancer,” says Anita Nelson, MD, professor and chair of the obstetrics and gynecology department at Western University of Health Sciences in Pomona, CA. “I think those estimates can be used as a basis for making screening recommendation, but also to identify women who might be candidates for chemoprevention — to actually reduce their risks of developing the cancer, rather than just detecting it early enough.” (One such online resource is the Breast Cancer Risk Assessment Tool, available at: https://www.cancer.gov/bcrisktool/)
REFERENCES
- Radhakrishnan A, Nowak SA, Parker AM, et al. Physician breast cancer screening recommendations following guideline changes: Results of a national survey. JAMA Intern Med 2017; doi: 10.1001/jamainternmed.2017.0453.
- Oeffinger KC, Fontham ET, Etzioni R, et al; American Cancer Society. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA 2015;314:1599-1614.
- Siu AL; U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2016;164:279-296.
- American College of Obstetricians-Gynecologists. Practice bulletin no. 122: Breast cancer screening. Obstet Gynecol 2011;118(2 Pt 1):372-382.
- Grady D, Redberg RF. Physician adherence to breast cancer screening recommendations. JAMA Intern Med 2017; doi: 10.1001/jamainternmed.2017.0458.
- Miller AB, Wall C, Baines CJ, et al. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: Randomised screening trial. BMJ 2014;348:g366.
A recently published research letter contains in-depth information about breast cancer screening recommendations physicians give their patients amid recent guideline changes.
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