'We're well equipped': Personalized care should lead PCP breast cancer screening decisions

Key takeaways:

• Some medical organizations have conflicting guidelines concerning breast cancer screening.
• Although guidance can be helpful, an expert said individualized care should ultimately guide PCPs’ decision-making.

Considering conflicting clinical guidelines, primary care providers should focus on individualized decision-making when deciding if and when a patient should be screened for breast cancer, according to experts.

Preventive services like cancer screenings are a critical part of primary care practices, Tochi Iroku-Malize, MD, MPH, MBA, FAAFP, chair of the board of directors for the American Academy of Family Physicians, told Healio.

“The idea of doing screening is so that we can detect illnesses early,” Iroku-Malize said. “If we identify them early, we're more likely to be able to intervene and help the patients live longer, healthier, more satisfying lives. Skipping these preventive services can be dangerous because some of these diseases and conditions may not be found in time for an effective treatment, and this includes breast cancer screening.”

This is also important considering breast cancer’s prevalence. In the United States, there are roughly 240,000 cases of breast cancer diagnosed and about 42,500 deaths each year, according to the CDC.

It is also the most common cancer among women, William Hood, DO, an osteopathic physician specializing in OB/GYN and member of the American Osteopathic Association (AOA), said.

“It is reported that one in eight women will be diagnosed with breast cancer,” Hood said. “Screening and prevention are very essential, especially if you do have breast cancer — that way we can catch it as quickly as possible.”

Iroku-Malize said a large part of the PCP’s job is to discuss if and when breast cancer screening — among other preventive care — is right for patients “and develop a plan for that early detection to make sure that they are able to have a healthier life.”

However, breast cancer screening comes with one complication: conflicting guidelines from some major medical organizations.

“As clinicians, we're really trying to stay on top of the latest research,” Iroku-Malize said. “Research is important because that helps to modify what we need to do based on the existing new information so that we can do the best things for our patients.”

Guidelines and evidence

The U.S. Preventive Services Task Force recommends that all women aged 40 to 74 years be screened for breast cancer every other year. However, the American College of Radiology recommends a more conservative approach: that all women receive a breast cancer risk assessment by the age of 25 years to determine if screening is needed earlier than age 40 years.

“At the AAFP, we do support the current USPSTF clinical preventive service recommendation for breast cancer screening,” Iroku-Malize said. “The AAFP did submit comments on the USPSTF draft recommendation on breast cancer screening, and we're waiting to find out what the final recommendation is so that we can review it and determine whether to support that new recommendation.”

Teresa Hubka, DO, an osteopathic physician specializing in OB/GYN and president elect of the AOA, said she also agrees with the USPSTF’s biannual screening recommendation.

“Breast health is important in women’s health screenings,” she said.

Epic Research recently published an analysis of mortality rates after breast cancer diagnoses based on whether women had a mammogram annually or every 2 years before being diagnosed. The study, which included 25,512 women aged 50 to 74 years who were not identified as having a high risk for breast cancer before being diagnosed with the disease between Jan. 1, 2018, and Aug. 1, 2022, revealed that women who were screened every year saw a 17% lower risk for all-cause mortality following diagnosis.

Notably, Iroku-Malize mentioned that the USPSTF recommendation is not a hard rule and still gives PCPs the room to personalize their care, “which is what we've done in the past and will continue to do.”

“The guidelines are good in general, but at the end of the day, you take them and then you also figure out how to apply it to your patients,” she said.

When she considers making breast cancer screening decisions with patients, Iroku-Malize said one case in particular comes to mind: a woman who was younger than 50 years with no family history discovered a lump in her breast while taking a shower.

Based on the guidelines, a physician would not have screened the patient for breast cancer, but the physical presence of an anomaly warranted further investigation, she said. After the physical exam confirmed what the patient had said, she got a mammography and then a biopsy that confirmed her diagnosis. They were able to begin treatment immediately, Iroku-Malize said.

“In that case, going outside the guidelines in order to specifically tailor to this individual patient was important,” she said. “So that's where we say that you have to consider all of the information regardless of what that is, and that that's whether it's hypertension, diabetes, etc.”

Individualizing care

The USPSTF says the decision to start screening younger individuals should be “based on the individual patient's risk factor, then their family and medical history,” Iroku-Malize said.

“Family physicians, we’re well equipped ... utilizing that long-term, close relationship with patients gives us a comprehensive view of what's going on with patients’ health and their individual needs,” she said. “We discuss with each patient if and when breast cancer screening is right for them, and then develop that plan for that early detection of breast cancer.”

These discussions include the patient’s risk for breast cancer, patient preferences, evidence regarding each screening test, the risks that accompany each test and family history, Iroku-Malize said.

“Anything you do for your patient, at the end of the day, you still have to take into consideration that individual patient, their family history, their social environment, and all the other things that are affecting their lives because each individual is unique,” she said. “Health equity is integral to what we do in family medicine.”

The Epic Research study revealed that, after a diagnosis of breast cancer, some populations had an increased risk for all-cause mortality: Black women, those who are older than 60 years, those living in a rural area and those living in a more socially vulnerable area. The CDC has also reported that, compared with all other women, Black women have a higher rate of death from breast cancer.

“Social determinants of health definitely impact patients’ access to equitable care, high-quality care, and this includes the preventive screening,” Iroku-Malize said. “Family physicians are uniquely connected to their communities, and we witness firsthand the social and structural inequities in health and health care that can affect racial and ethnic minorities and rural communities, etc. So, keeping this in mind, that helps to tailor our approach as we take care of the patients that we're trying to serve.”

References:

• Breast cancer. https://www.cdc.gov/cancer/breast/basic_info/index.htm. Accessed Jan. 31, 2024.
• Epic Research. Annual screening associated with lower all-cause mortality risk after breast cancer diagnosis compared to screening every two years. https://epicresearch.org/articles/annual-screening-associated-with-lower-all-cause-mortality-risk-after-breast-cancer-diagnosis-compared-to-screening-every-two-years. Published Jan. 4, 2024. Accessed Jan. 31, 2024.
• Yedjou CG, et al. Adv Exp Med Bio. 2020;doi:10.1007/978-3-030-20301-6_3.