Conflicting Breast Cancer Screening Guidelines Lead to Varying Physician Recommendations

A new study published in JAMA Internal Medicine has found that the extent to which clinicians follow breast cancer screening guidelines for patients of different ages varies by their specialty and by which set of recommendations they trust most.

The major 3 guidelines differ in their recommendations for how often mammograms to screen for breast cancer should be performed on women of different ages. The most “hands-off” guidelines, which were issued by the US Preventive Services Task Force (USPSTF), recommend that women aged 40 to 49 years make a personalized decision with their doctors on whether to undergo screening and that women aged 50 to 74 should receive a mammogram every 2 years.

The American Cancer Society (ACS) guidelines are slightly more proactive, as they recommend personalized screening choices for women aged 40 to 44 years, annual screening from ages 45 to 54 years, then screening every other year for women aged 55 and older. Finally, the American Congress of Obstetricians and Gynecologists (ACOG) recommends the most prolific screening regimen, as its guidelines suggest women aged 40 and older should have mammograms every year.

With these conflicting guidelines in place, researchers used a clinician survey to determine which recommendations physicians actually followed and whether their actions differed if they specialized in family medicine/general practice, internal medicine, or gynecology. The frequency of recommending mammograms for women aged 50 to 54 years and 55 to 74 years was similar across all 3 types of clinicians, but gynecologists were significantly more likely than the others to recommend screening for patients aged 40 to 44, 45 to 49, and 75 or older.

There were also disparities in trusted guidelines, which seemed to affect screening tendencies. The ACOG guidelines garnered the most trust, as 26% of physicians reported they trusted these the most, compared with 23.8% who trusted the ACS guidelines most and 22.9% trusting the USPSTF guidelines most.

The physicians who said they trusted the USPSTF guidelines the most were significantly less likely to advise screening younger women than those who supported the other 2 guidelines. For instance, 60.8% of those favoring the USPSTF guidelines recommended screening patients aged 40 to 44, while 86.5% of those choosing ACS and 92.9% of those favoring ACOG reported the same. Similarly, the clinicians who trusted the USPSTF guidelines the most were significantly less likely to recommend screening women aged 75 or older.

An accompanying editorial also published in JAMA Internal Medicine called these findings “rather dispiriting,” as they indicate that “a large proportion of primary care physicians recommend screening mammography for women who are more likely to experience harms than benefits from the examination.”

The editorial’s authors pointed to the high false-positive rate of mammograms, and the associated harms like unnecessary breast imaging and emotional distress, as reasons clinicians should practice more restraint when recommending such screening. They also wrote that the fee-for-service payment system in the United States encourages the overuse of medical tests and a redesigned payment model could help to curb this occurrence. For instance, they suggested limiting coverage of tests that are determined by the USPSTF to have Grade D evidence, indicating the service has no net benefit or the benefits are outweighed by the harms, as well as increasing patient awareness to facilitate more informed decision-making about such testing.

“Ultimately, alternative payment systems that value evidence-based, patient-centered outcomes would improve patient care, choice, and satisfaction while decreasing wasteful spending,” the editorial concluded.