PCPs can help navigate screening guidelines, prevent breast cancer

CDC data show that breast cancer is the most common cancer in women, affecting approximately 123 out of every 100,000 women, and is the second leading cause of cancer death among women. That agency’s data also show that in 2013, the last year such data is available, the disease claimed 40,860 female lives.

The NIH has determined that mammograms are the most sensitive ways to screen for breast cancer, but the lack of a consensus among patient advocacy groups regarding when to get one has led to a bit of a controversy.

Richard Wender

These differing opinions include:

•the American Cancer Society (ACS) recommends that average risk women undergo regular mammogram screening starting at age 45; that women aged 40 to 45 years should have the opportunity to begin screening, and that women should transition to biennial screening at age 55 years with the option to continue annual screening;

•the American Congress of Obstetrics and Gynecology maintains that screening mammography be conducted annually for every woman aged 40 and older;

•the U.S. Preventive Services Task Force recommends biennial screening mammography for women aged 50 to 74 years, and that the decision to start screening mammography earlier than age 50 years should be an individual one, which mirrors the AAFP’s recommendation; and

•the ACP states that clinicians should adopt a cancer screening strategy that focuses on reaching all eligible persons with high-value screening options such as those mentioned above, while reducing overly intensive, low-value screening.

A survey by ABC News found that 86% of the 504 women asked, wrongly thought that guidelines stated that mammograms should start at age 30 or 40, and 65 percent saying this procedure should be done annually.

To help navigate the confusion, many women turn to their provider. A separate survey conducted by the Society for Women’s Health research indicating that 56% of the 3,501 women aged 18 and older asked, said their provider's recommendation is the most significant factor in scheduling a mammogram, providing an opportunity for primary care physicians (PCPs) to play a significant role in preventing this disease.

May 14 to May 20 is Women’s Health Week — a time, according to the CDC, to remind to women to take care of themselves, and to make their health a priority.

As part of this annual event, Healio Family Medicine talked with Richard Wender, MD, and chief cancer control officer, ACS, about the primary care physician’s role in ensuring women are screened and referred for care appropriately, as well as what more can be done to prevent breast cancer, and more.

Question: What is the best advice you can give a PCP to help a patient prevent breast cancer?

Answer: PCPs hold the key to cancer screening. The strongest predictor of whether or not screening occurs is if an individual receives a recommendation from their primary care clinician. Every PCP needs a screening policy: a team approach to screening that involves the entire office, reminder systems to prompt action when a patient is in the office, and a system to implement population outreach for the individuals who haven’t had a recent office visit. Every mammogram guideline recommends beginning the screening discussion at age 40 for average risk women, so a shared decision-making tool is also a useful addition. Encouraging one woman to get screened during an office visit is pretty straightforward. Achieving a high rate of cancer screening for a practice’s entire population is a lot of work and demands an office-wide system of care.

Finding breast cancer through screening is the best way to increase the likelihood of long-term cure. Finding ductal carcinoma in situ (DCIS) through screening can also lead to the prevention of progression to invasive cancer. Although not all DCIS progresses, many cases do.

Q: How do overweight and obesity and alcohol intake factor into breast cancer prevention?

A: Overweight and obesity is one of the great public health challenges we have ever faced. The association between body weight and breast cancer is complex. The strongest association is with weight gain after menopause. The association between obesity and pre-menopausal cancer is less clear. There are data that weight gain after a diagnosis of breast cancer results in slightly worse outcomes than maintaining or losing weight through healthy diet and exercise. We don’t really know if there is an absolute “safe” amount of overweight and obesity.

We’re also getting a little cavalier about alcohol intake and cancer risk. The risk associated with alcohol appears to be dose dependent — the less alcohol a woman drinks, the lower her breast cancer risk. And there appears to be no absolute threshold below which the risk is unaffected. The ACS has, for years, recommended a maximum of an average of one dose of alcohol, (a typical serving size depending on the type of beverage), per day for women. Reducing alcohol intake even lower than this may be even more effective in lowering breast cancer risk. Working with families to encourage healthy food choices and active life styles is a critical primary care responsibility.

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Q: Do you find that patients are confused about the breast cancer screening guidelines?

A: Interestingly, we have data that most primary care clinicians haven’t changed their approach to breast cancer screening and most women haven’t changed their preferences about when to start or how often to be screened. But there certainly are some women and some clinicians who are responding to guideline changes. In the end, though, primary care clinicians tend to pick an approach and stick to it. Finally, it’s likely that some women are confused and some clinicians are uncertain. I think this can result in ambivalence and a decreased focus on breast cancer screening in general. Every guideline group endorses mammography screening so loss of focus on screening is dangerous. We need to work harder to make sure that every primary care practice is offering regular mammography screening to every woman over age 40 with or without shared decision making.

Q: Besides screenings, what other steps can a PCP advise their patient about to prevent breast cancer?

A: We’re not doing enough to prevent breast cancer. The data are now clear that women who can maintain a normal body weight and stay active have a lower breast cancer risk than women who are overweight or obese. We also know that even small amounts of alcohol elevate risk, and this risk gets higher as the amount of alcohol goes up. Finally, knowing family history is really important. Many women are at above average risk and hundreds of thousands of women carry the BRCA gene. So knowing family history and responding to the information is vitally important.

Q: What additional efforts do you think are needed? Could you describe a scenario where you think PCPs and the medical community would be doing enough to fight breast cancer?

A: Some clinicians have misinterpreted the subtle difference in mammography guidelines as a loss in confidence in the effectiveness of mammography. Thus, some clinicians and many health care systems are not focusing on improving mammography rates as a quality improvement program.

In addition, the mortality disparity gap between [black] women and [white] is widening — and it has been widening for 30 years. The reasons for this are not simple. Although there may be some biologic differences, the gap strongly associated with income and access to care differences. We need to be investing in research to find causes and solutions to this disparity. We also need to shift some of the investment through the National Cancer Institute and other research funders towards testing community based solutions to increase timely initiation of treatment and completion of the entire treatment course.

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Q: What is the best advice you can give a PCP who has patient with breast cancer?

A: PCPs need to have a basic understanding of how the diagnosis and treatment of breast cancer is evolving. Assembling a skilled, multi-disciplinary treatment team is becoming a care standard. PCPs need to make sure women evaluate palpable lumps and abnormal mammograms in a timely manner. And if the biopsy shows DCIS or cancer, PCPs need to make sure that women are referred to a member of an interdisciplinary treatment team, often beginning with a surgical referral. Finally, PCPs often provide an important source of support and guidance throughout the period of active treatment.

In addition, many women experience long term effects of after the breast cancer diagnosis. Fatigue. Lymphedema. Anxiety. Depression. A PCP needs to anticipate these possibilities or identify them when they occur. Involving a team of specialists, such as physical therapists, psychologists and lymphedema specialists, to help women cope is often helpful. When it comes to survivorship, prescribing exercise can help fatigue. Some women may need to be referred for genetic evaluation. And all women need to keep up with cancer screening to screen for new primaries.

References:

American Congress on Obstetrics and Gynecology Statement on Revised American Cancer Society Recommendations on Breast Cancer Screening (accessed 05-15-2017)
Breast Cancer Confusion Widespread, Survey Finds (accessed from ABC News website 05-15-2017)
Breastcancer.org webpage on U.S. Breast Cancer Statistics (accessed 05-15-2017)
CDC webpage on National Women's Health Week (accessed 05-15-2017)
CDC's webpage on Cancer Among Women (accessed 05-15-2017)
CDC's webpage on Breast Cancer Statistics (accessed 05-15-2017)
NIH National Cancer Institute webpage on mammograms (accessed 05-15-2017)
USPSTF, AAFP Issue Final Breast Cancer Screening Recommendations (accessed from AAFP’s website 05-15-2017)
Screening for Cancer: High Value Care from ACP (accessed from ACP’s website 05-15-2017)
Women Want Breast Cancer Screening with Better Detection and Fewer Follow-up Tests (accessed from PRNewswire 05-15-2017)

Disclosure: Wender reports no relevant financial disclosures.