How Closely Are Doctors Following Breast Cancer Screening Guidelines?

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Breast cancer screening has been a much-discussed topic in the last several years. Several large studies, including a review by the U.S. Preventive Services Task Force in 2009 and a study on the causes of death in the United Kingdom in 2013, have questioned the value of screening mammograms.

Doctors who question the value of mammograms say that while mammograms do save lives, for each breast cancer death prevented, three to four women are overdiagnosed. Overdiagnosis means either:

  • a screening mammogram finds a suspicious area that would have been eventually diagnosed as cancer by other means, without any effect on prognosis
  • a screening mammogram finds a suspicious area that never would have affected a woman’s health if it hadn’t been found or treated

False positive results from screening mammograms also have helped fuel the debate about the value of breast cancer screening. When a mammogram shows an abnormal area that looks like a cancer but turns out to be normal, it’s called a false positive. Ultimately the news is good: no breast cancer. But the suspicious area usually requires follow-up with more than one doctor, extra tests, and extra procedures, including a possible biopsy. There are psychological, physical, and economic costs that come with a false positive.

These studies and the resulting stories in the media have fueled an ongoing debate about the value of screening mammograms.

Since that time, the American Medical Association, the American Congress of Obstetricians and Gynecologists, the American College of Radiology, the National Cancer Institute, and the National Comprehensive Cancer Network all have issued guidelines saying that all women should be eligible for screening mammograms starting at age 40.

In 2015, the American Cancer Society released updated breast cancer screening guidelines that recommend that women at average risk start regular annual screening with mammography at age 45 and move to screening every 2 years at age 55. The guidelines also say that women ages 40 to 44 should have the option to begin screening early and that women 55 and older should have the opportunity to continue screening every year if they choose. In 2016, the U.S. Preventive Services Task Force reissued its recommendations to recommend personalized screening decisions for women 40 to 49 followed by mammograms every 2 years for women 50 to 74.

Because these professional organizations don’t agree on mammogram guidelines, researchers wondered what doctors were recommending to their patients.

A study suggests that most doctors recommend annual mammograms for all women, no matter their age.

The research was published online on April 10, 2017 by JAMA Internal Medicine. Read the abstract of “Physician Breast Cancer Screening Recommendations Following Guideline Changes: Results of a National Survey.”

To do the study, the researchers mailed a survey to a national sample of 1,665 doctors; 871 doctors filled out and returned the survey.

The survey asked the doctors whether they typically recommended routine screening mammograms to women with no family history of breast cancer and no history of breast issues in various age groups and how often mammograms were recommended (every year or every 2 years). The survey did not ask the doctors if they engaged in personalized decision-making with their patients. The survey also asked which organization’s breast cancer screening guidelines the doctors trusted the most.

Of the doctors who filled out the survey:

  • the average age was about 53
  • 54.6% were men
  • 70.6% were white
  • 44.2% were general practitioners
  • 29.7% were internal medicine doctors
  • 26.1% were gynecologists
  • more than 50% had more than 20 years of experience seeing patients

Overall:

  • 81% of the doctors recommended screening to women ages 40 to 44
  • 88% of the doctors recommended screening to women ages 45 to 49
  • 67% of the doctors recommended screening to women age 75 and older

Compared to general practitioners and internal medicine doctors, gynecologists were more likely to recommend screening for women of all age groups.

Among the doctors who recommended screening, most of them recommended annual mammograms:

  • 62.9% recommended annual screening for women ages 40 to 44
  • 66.7% recommended annual screening for women ages 45 to 49
  • 52.3% recommended annual screening for women age 75 and older

More than a quarter of the doctors said they trusted the American Congress of Obstetricians and Gynecologists breast cancer screening guidelines the most:

  • 26.0% trusted the American Congress of Obstetricians and Gynecologists recommendations the most
  • 23.8% trusted the American Cancer Society recommendations the most
  • 22.9% trusted the US. Preventive Services Task Force recommendations the most

“Sometimes when cancer screening guidelines change, they recommend that we do less, that we start screening later, screen less frequently and end screening after a certain age,” said Craig Pollack, associate professor of medicine at Johns Hopkins University and a co-author of the study. “I think this can be incredibly challenging for doctors and patients because we are used to doing things in a certain way, so telling people to do less can run counter to our prior experiences caring for patients. Doctors need to work with patients to help them come to breast cancer screening decisions that are right for them.”

Having several different recommendations on when women should start getting mammograms and how often women should have mammograms is very confusing.

At Breastcancer.org, we believe that a woman’s best chance for early detection requires coordination of our current screening tools:

  • high-quality mammography
  • clinical breast exam
  • breast self-exam

To not use all three tools in women ages 40 to 45 and to do mammograms alone (without clinical or self-exam) in women older than 45 are missed opportunities for early detection.

The reality is that every woman is at risk for breast cancer, and this risk tends to increase over time. It’s important to understand and regularly update your health information related to breast cancer risk throughout your life with your doctor. To get the conversation started, here are some points to talk to your doctor about:

  • family history of breast or other related cancers (ovarian, melanoma)
  • any test results for abnormal genes linked to a high risk of breast cancer
  • results of past breast biopsies, even if they were benign
  • personal history of being treated with radiation to the face and/or chest before age 30
  • breast density
  • weight, if you’re overweight or obese
  • level of physical activity
  • any use of postmenopausal combined hormone replacement therapy (HRT)
  • alcohol consumption, if you regularly drink more than 3 alcoholic beverages per week
  • the amount of processed food and trans fats you eat
  • your smoking history
  • whether or not you had a full-term pregnancy or breastfed

Breastcancer.org stands by its recommendation that ALL women have mammograms annually starting at age 40. We also believe that monthly breast self-exam and annual physical exams by a doctor are essential parts of an overall breast cancer screening strategy. If you’re at high risk for breast cancer, you should talk to your doctor about starting annual mammograms at a younger age and consider other screening tools (such as MRI or ultrasound) to maximize the opportunity for early detection.

There's only one of you and you deserve the best care possible. Don't let any obstacles get in the way of your regular screening mammograms.

  • If you're worried about cost, talk to your doctor, a local hospital social worker, or staff members at a mammogram center. Ask about free programs in your area.
  • If you're having problems scheduling a mammogram, call the National Cancer Institute (800-4-CANCER) or the American College of Radiology (800-227-5463) to find certified mammogram providers near you.
  • If you find mammograms painful, ask the mammography center staff members how the experience can be as easy and as comfortable as possible for you.
  • If you’re concerned about unknown results or being called back for more testing, talk to your doctor about what happens when mammogram results are unclear, as well as what to expect if you’re called back for more testing.

For more information on mammograms and other tests to detect and diagnose breast cancer, visit the Breastcancer.org Screening and Testing section.



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