Lat­est mam­mo­gram guide­lines stress need for doc­tor/pa­tient di­a­logue

Modern Healthcare - - NEWS - By Steven Ross John­son

The Amer­i­can Can­cer So­ci­ety’s re­cent up­date of its guide­lines, the first in more than a decade, changed the rec­om­mended age from 40 to 45 for some women to be­gin get­ting rou­tine mam­mo­grams.

The ACS now rec­om­mends that women ages 40 to 44 should choose to be­gin an­nual screen­ing “if they wish to do so.”

Ex­perts say that word­ing rep­re­sents a marked shift.

The ACS “did a re­ally nice thing in stress­ing the role of pa­tient pref­er­ence and the need for it to be in­di­vid­u­al­ized rather than th­ese cut-and-paste types of rec­om­men­da­tions,” said Dr. Sand­hya Pruthi, pro­fes­sor of medicine at the Mayo Clinic. “To un­der­stand that the fu­ture of breast can­cer screen­ing is a more per­son­al­ized ap­proach is huge.”

The guide­lines urge providers to in­form pa­tients of the ben­e­fits and harms of screen­ing at ear­lier ages.

Pruthi and oth­ers say that’s al­ready hap­pen­ing.

“There’s a huge em­pha­sis on shared de­ci­sion­mak­ing be­tween the pa­tient and their physi­cian,” said Dr. Laura Shepardson, as­so­ciate di­rec­tor of breast imag­ing at the Cleve­land Clinic. “It’s re­ally im­por­tant for a pa­tient and for the doc­tor to un­der­stand what the pa­tient’s val­ues and pref­er­ences are.”

About 230,000 women in the U.S. are di­ag­nosed an­nu­ally with breast can­cer, which ranks as the sec­ond-lead­ing cause of can­cer mor­tal­ity among women, with more than 40,000 deaths an­nu­ally. Ac­cord­ing to the ACS, women whose can­cer is de­tected at Stage 1 have a 100% rate of sur­vival over the first five years af­ter ini­tial di­ag­no­sis com­pared with 22% among those where the dis­ease is not de­tected un­til Stage 4.

But some ex­perts say rec­om­mend­ing that women de­lay reg­u­lar screen­ing un­til ages 45 or 50 is a dis­ser­vice to pa­tients and makes it more dif­fi­cult for younger women to get screened.

“Ev­ery woman should be able to get a mam­mo­gram at age 40, and if we’re rais­ing the age it may make it harder for them to do this,” said Dr. Mary Rosser, spokes­woman for Amer­i­can Col­lege of Ob­ste­tri­cians and Gyne­col­o­gists.

Ex­perts stress that early de­tec­tion out­weighs any cost, dis­com­fort or anx­i­ety. But rou­tinely screen­ing younger women has led to false pos­i­tives and un­nec­es­sary treat­ment such as biop­sies, ra­di­a­tion and even chemo­ther­apy or surgery.

The ACS’ up­dated guide­lines say switch­ing to ev­ery other year at age 55 makes sense be­cause tu­mors in women af­ter menopause tend to grow more slowly. Also, older women’s breasts are usu­ally less dense, so can­cer is more vis­i­ble on mam­mo­grams, said Dr. Kevin Oeffin­ger, chair­man of the so­ci­ety’s breast can­cer guide­line panel and di­rec­tor of the can­cer sur­vivor­ship cen­ter at Me­mo­rial Sloan Ket­ter­ing Can­cer Cen­ter in New York.

The ACS’ guide­lines fol­low ad­vice sim­i­lar to that pro­posed in 2009 by the U.S. Pre­ven­tive Ser­vices Task Force, an in­de­pen­dent body that makes rec­om­men­da­tions on clin­i­cal pre­ven­tive ser­vices and in­flu­ences Medi­care cov­er­age. The panel rec­om­mended that women at av­er­age risk for breast can­cer start get­ting mam­mo­grams af­ter they turn 50 and then ev­ery two years.

The task force guide­lines also take the ACS po­si­tion on screen­ing be­fore 50. It rec­om­mends that screen­ings should be avail­able for younger pa­tients, who could make that de­ci­sion af­ter con­sult­ing with their physi­cian.

And dis­cus­sions with a physi­cian may be the pru­dent route for pa­tients, con­sid­er­ing the am­bi­gu­ity that ex­ists over what is the right ap­proach.

While the ACS guide­lines sug­gest women be­gin screen­ing at age 45 and the task force rec­om­mends age 50, the Amer­i­can Col­lege of Ob­ste­tri­cians and Gyne­col­o­gists and the Amer­i­can Col­lege of Ra­di­ol­ogy asks women to be­gin screen­ings at 40.

The dif­fer­ing views are con­fus­ing for both doc­tors and pa­tients.

“It would be nice to speak with one voice,” said Dr. Robert Wer­gin, board chair for the Amer­i­can Academy of Fam­ily Physi­cians. “Mul­ti­ple dif­fer­ent guide­lines do cre­ate con­fu­sion.”

Shepardson said the am­bi­gu­ity caused by dif­fer­ing guide­lines make it even more im­por­tant for providers to adopt the per­son­al­ized ap­proach when mak­ing such de­ci­sions.

“It’s im­por­tant to re­mem­ber rec­om­men­da­tions are just that—they are rec­om­men­da­tions,” she said. “You can use them to help you make de­ci­sions, but it shouldn’t be the ab­so­lute de­cid­ing fac­tor with­out con­sid­er­ing each pa­tient’s in­di­vid­ual sit­u­a­tion.”

And in fact, a study last year by the Pow­ell Cen­ter for Women’s Health at the Univer­sity of Min­nesota Med­i­cal School showed that cul­tural dif­fer­ences, es­pe­cially within im­mi­grant com­mu­ni­ties, fac­tor into a woman’s de­ci­sion to be screened for breast can­cer. Th­ese women, who take mod­esty into con­sid­er­a­tion when mak­ing their health­care choices, al­ready ex­pe­ri­ence dis­par­i­ties in care.

Shepardson added that there has been dis­cus­sion on cre­at­ing a na­tional con­sen­sus on breast can­cer screen­ing guide­lines by the ma­jor stake­hold­ers, but she was un­cer­tain if any progress had been made to­ward those ef­forts.

“It would be nice to speak with one voice. Mul­ti­ple dif­fer­ent guide­lines do cre­ate con­fu­sion.” Dr. Robert Wer­gin, board chair for the Amer­i­can Academy of Fam­ily Physi­cians

Dis­cus­sions with a physi­cian on how of­ten to get a mam­mo­gram may be the pru­dent route for pa­tients, con­sid­er­ing the dis­agree­ment among ex­perts.

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