Study: Do physicians recommend breast cancer screenings based on guidelines?

IN-DEPTH REVIEW OF RESEARCH

Study background:

A number of screening mammography guidelines are available for physicians. Unfortunately, as the authors of this study state, “Different professional societies and organizations continue to disagree over the optimal time to initiate and discontinue breast cancer screening mammography and the optimal screening interval.”

• The American Cancer Society (ACS) 2015 guidelines recommend personalized screening decisions for women 40-44 years old, followed by annual screening starting at 45 years old, and biennial screening for women 55 years or older.
• The US Preventive Services Task Force (USPSTF) 2016 guidelines recommend personalized screening decisions for women ages 40-49, followed by biennial mammograms for women ages 50-74.
• The American Congress of Obstetricians and Gynecologists (ACOG) 2011 guidelines recommend yearly mammograms for women 40 years or older.

This study authors state that physician recommendation is “The most important determinant for patients obtaining screening.” Archana Radhakrishnan, MD and her colleagues from Johns Hopkins University and other institutions surveyed physicians to learn which recommendations they were making to their patients regarding breast cancer screening. Her goal was to see how physicians were incorporating recent guideline recommendations into their clinical practices.  Radhakrishnan’s work was published in JAMA Internal Medicine in June 2017.

Researchers of this study wanted to know:

Guidelines outlining the best time to begin breast cancer screening mammography, and how often and how long screening should continue are updated frequently. In addition, different professional societies and organizations that make these recommendations often disagree. The researchers wanted to know whether physicians follow more recent guidelines when making breast cancer screening recommendations for patients who do not have a family history of breast cancer, and which recommendations they trusted the most for their patients.

Population(s) looked at in the study:

The physicians involved in the study were part of the Breast Cancer Social Networks study (CanSNET). Surveys were mailed to 2,000 eligible physicians who provided primary care or general gynecologic care to women 40 years or older. After excluding ineligible physicians, the adjusted response rate was 52.3% (871 of 1665). Of these, 871 self-reported their breast cancer screening practices. Physicians were asked whether they typically recommended routine screening mammograms for women with no family history of breast cancer and no prior breast issues, and what recommendations they made to different age groups and at what intervals. They were asked to indicate which organization’s screening guidelines they most trusted. They were not asked whether they practiced individualized decision-making.

Study findings: 

This study found that most physicians recommend breast cancer screening beginning at age 40. Of the three guidelines in the survey, this reflects only the ACOG’s recommendation; both the ACS and the USPSTF recommend screening beginning at 45 and 50 respectively. This study suggests that many physicians do not follow the most current of the three guidelines.

• About 81% of physicians would recommend breast cancer screening to women ages 40 to 44.
• About 88% would recommend screening to women 45-49 years old.
• About 67% would recommend screening in women 75 years or older.

Physicians reported which guidelines they trusted the most:

• About 26% most trusted ACOG guidelines.
• About 24% most trusted ACS guidelines.
• About 23% most trusted USPSTF guidelines.

Differences in physician recommendations were based on which guideline they trusted most.  Physicians who trusted ACS and ACOG guidelines were significantly more like to recommend screening in younger women compared to those who trusted USPSTF guidelines.

Finally, this study found that gynecologists were more likely to recommend screening for women of all age groups compared to internal medicine physicians and family medicine physicians.  This is likely the result of their professional organization, ACOG, recommending annual screening beginning at age 40.

Limitations:

While this study identifies differences in breast cancer screening recommendations among physicians, the researchers did not ask physicians why they favor one guideline over another. However, in an accompanying editorial, “Physician Adherence to Breast Cancer Screening Recommendations” Deborah Grady, MD and Rita F Redberg, MD speculate on why some physicians do not follow evidence-based guidelines, noting:

• medical payment systems in the U.S. more frequently reward ordering tests and procedures than taking the time to talk to patients about the risks and benefits of screening 
• physicians’ fears of litigation may result in overuse of screening
• the possibility that physicians over-recommend screening because of decades of media hype, including the long-standing message that early detection must be good and that knowing is better than not knowing.

It is important to note that neither the authors of the study nor the authors of the editorial mention the fact that current National Comprehensive Cancer Network (NCCN) Guidelines also recommend mammograms beginning at age 40. The NCCN Guidelines, which are updated annually, were not part of the physician survey.

Unfortunately, the study design limits the conclusions that can be drawn about why doctors make certain breast screening recommendations. 

Conclusions:

This study suggests that not all physicians may follow recent breast cancer screening guidelines.  More work needs to be done to understand why this is and how ever-evolving guidelines can be better implemented into clinical practice. Importantly, this study highlights the need for truly informed patient-physician shared decision making. Incorporating evidence and patient preferences into clinical practice and decreasing the influence of non-evidence based factors may ultimately reduce unnecessary screening.   

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Posted 8/8/17