New mammogram guidelines send patients to doctors for explanations
■ Controversy over a task force's recommendations has physicians spending more time talking with patients about breast cancer screening.
By Christine S. Moyer — Posted Dec. 21, 2009
When female patients in their 40s ask Lancaster, Pa., ob-gyn Charles Castle, MD, for his advice on mammograms, he tells them his opinion has not changed.
He still follows breast cancer screening guidelines from the American College of Obstetricians and Gynecologists, which recommend women age 40 to 49 get mammograms every one or two years. And he encourages patients to do breast self-exams, even though the U.S. Preventive Services Task Force recommended against that in screening guidelines released Nov. 16.
Patients "are concerned that there seems to be differing opinions from the experts of what's appropriate," he said. "Frankly, the [task force's] guidelines are contrary to what we have been telling patients for years."
The new guidelines have renewed debate about when routine screening mammograms should be given. Alarmed by the revisions, patients are going to their doctors with questions and concerns about what to do. For physicians already pressed for time, the discussions mean explaining the recommendations to patients, separating fact from fiction and determining the best course of action.
Dr. Castle has been spending an average two to three minutes more with each patient since the revisions were released. "It's definitely an issue that's being raised. And it takes some additional time."
Much of the anxiety surrounds task force recommendations against providing routine mammography screening for women younger than 50 and against teaching women breast self-examination. The new guidelines also say women 50 to 74 should get a mammogram every two years.
The revisions are a shift from guidelines issued in 2002 that called for mammograms every one to two years for all women older than 40.
Four days after the task force's announcement, ACOG released new cervical cancer screening guidelines, which recommend that women start getting Pap smears for cervical screening at age 21 and continue every two years through age 29. This changes 2003 ACOG guidelines calling for screening to begin about three years after the onset of sexual activity and continue annually through age 29.
Women age 30 and older who have had three consecutive negative Pap smears may be screened once every three years. The revised recommendations also say women with at least three consecutive negative Pap tests and no abnormal tests in the previous 10 years should stop receiving screening sometime between age 65 and 70. Previous recommendations did not set an upper age limit for screening. These guidelines do not apply to women at high risk.
The release of the two sets of guidelines within days of each other was a coincidence, said David Soper, MD, chair of ACOG's Gynecological Practice Bulletin Committee, which reviewed the recommendations. Dr. Soper also is a professor of obstetrics and gynecology at the Medical University of South Carolina College of Medicine.
"The timing was unfortunate, because when you deal with public health issues that have a huge impact, you can quickly get overloaded," said Len Lichtenfeld, MD, deputy chief medical officer of the American Cancer Society and an oncologist in Atlanta. "Not only can the patients get overloaded, but so can the physicians."
Health insurance coverage is not expected to change due to either organization's cancer screening guidelines, said Susan Pisano, a spokeswoman for America's Health Insurance Plans.
Explaining screening guidelines
Joseph W. Stubbs, MD, who practices internal medicine and geriatrics in Albany, Ga., said his patients are split on the task force's revised mammography guidelines. Half are not interested in the data the task force used to shape its decision; half are relieved they no longer need annual mammograms.
Regardless of their initial reactions, Dr. Stubbs, who also is president of the American College of Physicians, discusses the guidelines with patients, focusing on dispelling misinformation, such as concerns that the task force of doctors and scientists was formed by the government to ration care.
He tells patients, "There are some good things and not so good things about mammograms [for women in their 40s]. Let's talk about you as an individual and what would be best for you."
He added, "I tell them that we have to balance this [decision] between the rare instances that breast cancer is found and [the harms, including] false-positives and unnecessary biopsies leading to psychological trauma and scarring."
Rutherfordton, N.C., ob-gyn Douglas Sheets, MD, said many women younger than 50 still want annual mammograms, even after he discusses the task force's recommendations and the evidence on which they were based. He sometimes advises screening every two years for patients in their 40s who are low-risk but want mammograms.
But Dr. Sheets, president of the North Carolina Medical Society, said some patients are so concerned about the guidelines that he has had to reschedule their appointments to allow more time for discussion. "It just takes more time sitting with patients and answering their questions and reviewing their risk factors again. And that backlogs your office, if nothing else."
Screening saves lives
Dr. Lichtenfeld said the task force's recommendation against routine screening for women in their 40s was "ill-advised," and the revisions put doctors in a difficult position. He said annual breast cancer screening beginning at age 40 saves lives, even among women who are not considered high risk.
"Physicians can have a conversation with a patient about what they would like to do. But in no way can a physician look at a particular woman with average risk and say, 'You should be screened, or you should not be screened,' " he said.
Failure to diagnose breast cancer is one common reason why ob-gyns are sued, Dr. Sheets said. The task force's revised guidelines could increase this liability risk.
"It's a concern. But it's not going to keep me awake at night," said Dr. Sheets, who follows ACOG's breast cancer screening guidelines.
Early detection is partially credited for the steadily falling breast cancer death rate among women younger than 50, according to the American Cancer Society. Since 1990, the breast cancer death rate for women in that age group has decreased by 3.2% annually.
The ACS continues to recommend annual mammograms and clinical breast exams beginning at age 40. The National Cancer Institute and ACOG are continuing to follow their existing breast cancer screening guidelines but are reviewing them in light of the task force's revisions.
The American College of Radiology asked that the task force recommendations be rescinded to prevent the possibility of the new guidelines influencing policymakers as they shape health system reform legislation. The American Medical Association did not issue a statement on the guidelines, but existing AMA policy calls for annual mammograms starting at age 40.
With so many groups offering guidance, physicians are the ones patients turn to for clarity.
"The value of the reliable source. That's why I think patients tend to ask their own doctor, 'What do you believe in?' " Dr. Castle said.