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Large proportion of PCPs unnecessarily recommend screening mammography

A significant number of PCPs recommend breast cancer screening to women aged 40 years and older, likely exposing them to more harms than benefits, according to a research letter published in JAMA Internal Medicine.

The American Cancer Society (ACS), the US Preventive Services Task Force (USPSTF) and the American Congress of Obstetricians and Gynecologists (ACOG) “continue to disagree over the optimal time to initiate and discontinue breast cancer screening mammography and the optimal screening interval,” Archana Radhakrishnan, MD, MHS, from the division of general internal medicine at Johns Hopkins University, and colleagues wrote.

In October 2015, ACS recommended that women with an average risk for breast cancer undergo regular screening mammography beginning at age 45 years. In January 2016, USPSTF recommended biennial screening mammography for women aged 50 to 74 years and personalized screening decisions for women aged 40 to 49 years. In July 2011, ACOG recommended annual mammograms for women beginning at age 40.

Radhakrishnan and colleagues performed bivariate analyses to investigate the association between screening recommendations and physician specialty and organizational trust using data from the Breast Cancer Social Networks survey. A total of 871 eligible, randomly selected PCPs (73.9%) and gynecologists (26.1%) caring for women aged 40 years or older completed the survey on their breast cancer screening practices. Participants reported on whether they typically recommended routine screening mammograms to women with no family history of breast cancer and no prior breast issues in three age groups: 40 to 44 years, 45 to 49 years and 75 years or older. In addition, participants reported which organization’s screening guidelines they trusted most.

Results indicated that 81% of all participants recommended breast cancer screening to women aged 40 to 44 years, 88% to women aged 45 to 49 years and 67% to women aged 75 years and older. Gynecologists recommended screening for women of all ages more frequently than PCPs. Annual examinations for breast cancer were the most common recommendations among physicians who recommended screening: 62.9% for women aged 40 to 44 years; 66.7% for women aged 45 to 49 years; and 52.3% for women 75 years or older.

A previous study from Denmark found that breast cancer screening resulted in a substantial overdiagnosis, with approximately one in three women being treated unnecessarily. Another study from The Dartmouth Institute for Health Policy and Clinical Research revealed that screening mammography leads to overdiagnosis of small breast tumors.

Organizational trust was similar, with 26%, 23.8% and 22.9% of physicians trusting the ACOG, ACS and USPSTF guidelines the most, respectively. Compared with physicians who trusted the USPSTF guidelines, those who trusted the ACS and ACOG guidelines recommended screening younger women and women aged 75 years and older more often.

“In a nationally representative sample of physicians, we found that PCPs and gynecologists largely recommended screening to women 40 years or older,” Radhakrishnan and colleagues concluded. “We also found sharp differences in recommendations based on which guidelines physicians trusted most, which may suggest that current practices reflect both varying adherence to guidelines as well as differences in which guidelines are trusted. The results provide an important benchmark as guidelines continue evolving and underscore the need to delineate barriers and facilitators to implementing guidelines in clinical practice.”

In an accompanying editorial, Deborah Grady, MD, MPH, and Rita F. Redberg, MD, MSc, both from the University of California, San Francisco, wrote that these findings are “rather dispiriting.”

An evidence-based payment system is potentially the most effective way to discourage overuse of mammography, according to Grady and Redberg.

“Limiting coverage of tests known to be harmful is a win-win for patients and the national health care system,” they wrote. “Limiting coverage would reduce the harms of such tests, including radiation exposure, adverse effects, overdiagnosis, and the risks and anxiety associated with inevitable downstream additional testing, biopsies, and procedures related to false-positive test results. Limiting coverage for harmful tests would also save money for patients, the health care system, and ultimately the taxpayer.” – by Alaina Tedesco

Disclosures: All authors report no relevant financial disclosures.