Perspective from Renee Kendzierski, DO
Disclosures: The authors report no relevant financial disclosures.
March 17, 2021
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Screening recommendations among breast cancer centers rarely align with medical societies

Perspective from Renee Kendzierski, DO
Disclosures: The authors report no relevant financial disclosures.
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Most breast cancer centers in the United States recommend that women undergo screening mammography earlier and more often than recommended by national medical societies, data from a cross-sectional study in JAMA Internal Medicine show.

The United States Preventive Services Task Force (USPSTF) recommends screening mammography every 2 years for women aged 50 to 74 years, according to Jennifer L. Marti, MD, of the divisions of breast cancer and endocrine surgery at the department of surgery at Weill Cornell Medicine, and colleagues. The task force also recommends that the decision to undergo screening at an earlier age is based on an evaluation of individual risks. Meanwhile, the American Cancer Society recommends annual screening for women aged 45 to 55 years, then screening every 1 to 2 years thereafter.

Among 431 breast cancer centers that recommended an age to start screening mammography, 87.2% provided suggestions that conflict with national guidelines
Reference: Patel NS, et al. JAMA Intern Med. 2021;doi:10.1001/2021.0157.

The researchers wrote that both societies consider the “potential harms” of conducting screening too early, such as costs of low-value care, false-positive findings, unwarranted biopsies and operations, distress among patients and the overdiagnosis and overtreatment of “indolent cancers.”

“Women should decide if beginning screening at age 45 to 50, or earlier at age 40, is best for them,” Marti told Healio Primary Care. “Beginning at age 50, and undergoing screening every 2 years, is supported by the USPSTF, which is in line with most breast cancer screening recommendations around the world.”

Jennifer L. Marti

The researchers reviewed the online screening recommendations of 606 breast cancer facilities: 542 were accredited by the National Accreditation Program for Breast Centers, 47 had National Cancer Institute (NCI) designations and 17 had both statuses.

The researchers reported that 119 facilities did not specify the age to start screening mammography, how often screening should occur and information on discussions with physicians. Among these centers, 9.2% had a NCI designation.

Among the 487 facilities that did provide screening mammography recommendations on their websites:

  • 431 included a starting age;
  • 429 included a starting age and screening interval; and
  • 56 encouraged women to discuss screening with their physicians.

The researchers also noted that among 431 breast cancer centers that recommended a starting age for screening mammography:

  • 376 said screening should begin at age 40 years;
  • 35 said screening should begin at age 45 years; and
  • 20 said screening should begin at age 50 years.

Among the 487 breast cancer facilities that provided a screening mammography recommendation, fewer NCI-designated centers than non-NCI designated centers advised women to begin breast cancer screening at age 40 years (69.8% vs. 78.1%). However, NCI-designated centers more frequently encouraged women to talk to their physicians about screenings (17% vs. 10.8%). Of the 429 centers that recommended a starting age and screening interval, 347 offered recommendations that differed from those of national societies.

With the benefits of screening mammography “often overestimated” and the cons “often greatly underestimated” by most breast specialists, Marti emphasized the importance of shared decision-making.

She added that an ongoing trial known as the Women Informed to Screen Depending on Measures of Risk, or WISDOM, trial “may help determine appropriate screening intensity for individual patients.” She also called for more research on visual decision aids that illustrate possible benefits and drawbacks to mammography, as well as “ideal” screening guidelines for Black women, since these women may have been underrepresented in previous trials.

In a related editorial, Anand R. Habib, MD, a resident physician in the department of medicine at the University of California at San Francisco, and colleagues cautioned that the disagreement between breast cancer center websites and national guidelines may cause confusion and tension between patients and their primary care physicians.

“Breast cancer centers with clear financial benefits from increased mammography rates may wish to reconsider offering recommendations that create greater referral volume but conflict with unbiased evidence-based USPSTF guidelines and have the potential to increase harms among women,” they wrote.

References:

Habib AR, et al. JAMA Intern Med. 2021;doi:10.1001/jamainternmed.2021.0161.

Patel NS, et al. JAMA Intern Med. 2021;doi:10.1001/2021.0157.