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Do physicians recommend breast cancer screenings based on guidelines?


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Several guidelines help physicians decide when a woman should begin screening for breast cancer and how often she should be screened. However, are these guidelines put into use in the clinic? (8/8/17)


STUDY AT A GLANCE

This study is about:

  1. Whether doctors are following recent changes to guidelines for screening mammography for women with no family history of breast cancer or previous breast problems, and
  2. Identifying which recommendations doctors are following.

Why is this study important?

Doctor recommendation has a strong influence on patients’ decisions about cancer screening. However, sometimes doctors’ recommendations do not take into account medical guidelines and patient preferences.

Several different professional guidelines exist for mammograms for women of average risk for breast cancer. Each recommendation differs on:

  • Age to begin screening
  • Age to end screening
  • Frequency of mammograms

The goal of cancer screening is to try to detect cancer earlier, when it is most easy to treat. But cancer screening can come with tradeoffs. False positive results (for example, an abnormal mammogram that turns out not to be cancer), can lead to unnecessary callbacks and/or biopsies that increase stress and anxiety. Overdiagnosis can happen when screening detects a very slow-growing, non-aggressive cancer that might not require treatment.

It is important to know if doctors are following guidelines, and if so, which ones, when making breast cancer screening recommendations to patients. Several guidelines suggest personalized screening for patients. This requires doctors to know their patients’ medical and family health history, educate their patients about benefits and risks of screening, and understand their patients’ individual preferences and tolerance for false positives.

Study findings: 

Professional societies and organizations do not all agree about when women of average risk for developing breast cancer should begin routine mammogram screening, the frequency of those screenings, and for how long women should continue to be screened. (It is important to note that these recommendations are not for women with increased risk, such as BRCA mutation carriers or those with a family history.)

The researchers surveyed physicians to see how many routinely follow guidelines from one of these organizations: 

  • The American Cancer Society (ACS): 
    • In 2015 the ACS revised their guidelines to recommend personalized screening decisions for women ages 40-44, followed by annual screening starting at age 45, and screening every two years for women ages 55 or older. Women should continue screening as long as they are healthy and have a reasonable life expectancy.
  • The US Preventive Services Task Force (USPSTF):  
    • In 2016 the USPSTF revised their guidelines to recommend personalized screening decisions for women ages 40-50, followed by mammograms every two years for women ages 50-74.
  • The American Congress of Obstetricians and Gynecologists (ACOG):  In 2011 ACOG published guidelines recommending yearly mammograms for women 40 years or older.

The survey results showed the following:

  1. Among doctors who were surveyed:
    • About 81% would recommend screening to women ages 40 to 44.
    • About 88% would recommend screening to women ages 45-49.
    • About 67% would recommend screening in women ages 75 years or older.
  2. Doctors reported which guidelines they trusted the most:
    • About 26% trusted ACOG guidelines the most.
    • About 24% trusted ACS guidelines the most.
    • About 23% trusted USPSTF guidelines the most.
  3. Differences in doctor recommendations were based on which guideline they trusted most. Doctors who trusted ACS and ACOG guidelines were significantly more likely to recommend screening for younger women compared to those who trusted USPSTF guidelines.

What does this mean for me?

The results of this study are particularly important for average-risk women who are age 40 and above.  Screening recommendations are different for patients who have an increased risk of breast cancer due to an inherited mutation in a hereditary breast cancer gene, a strong family history of the disease, a previous breast biopsy demonstrating a high-risk lesion, or a previous diagnosis of breast cancer. Women who are at high risk should be aware of these guidelines. Women should make sure that they share their family history of cancer and other breast cancer risk factors with their doctor.

This study suggests that doctors’ recommendations for women at average risk for cancer vary. This difference may be due to which guideline doctor’s trust most (ACOG, ACS, USPSTF, or other). However, it is not known why doctors trust one guideline more than others. Many guidelines encourage shared decision-making. This means that the doctor and patient decide together which recommendations to follow. Patients should discuss their family history of cancer with their doctors to decide which screening schedule is most appropriate for them.

Questions to ask your health care provider:

  • Are you aware of my family history of cancers?
  • At what age do you suggest I begin screening mammograms and why?
  • Are there any risks to starting mammograms at a younger age?
  • How often should I get screened for breast cancer?
  • What should I do if I feel a lump in my breast?

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

References

Radhakrishnan A, Nowak SA, Parker AM, et al. “Physician Breast Cancer Screening Recommendations Following Guideline Changes: Results of a National Survey.”  JAMA Internal Medicine. 2017; 177(5): 877-878.

Grady D and Redberg, Rf.  “Physician Adherence to Breast Cancer Screening Recommendations.” JAMA Internal Medicine. 2017; 177(6):  763-762.

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