The time has come for an individualized approach to breast cancer screening, and that should be rooted in a shared decision between a woman and her physician, say the authors of a new essay published in JAMA.
Shared decision making in the setting of cancer screening isn’t a new idea. Several countries, such as France, Switzerland, and the United Kingdom have moved mammography screening programs in that direction. In the United States, shared decision making about prostate-specific antigen (PSA) testing for prostate cancer is now part of standard guidelines and was preceded by similar debate.
In their essay, Nancy Keating, MD, MPH, and Lydia E. Pace, MD, MPH, two physicians from Brigham and Women’s Hospital in Boston, Massachusetts, point out that other organizations, notably the American Cancer Society, have joined the US Preventive Services Task Force (USPSTF) in recommending a more individualized approach to breast cancer screening.
Despite these recommendations, US screening practices have not changed much. A survey of primary care practitioners (PCPs) in 2016 found that their recommendations for screening were high across all patient age groups, the authors note. More than 80% of nearly 900 surveyed PCPs stated that they would recommend screening to women aged 40 to 44 years, even though major guidelines recommend against routine screening in that age group (JAMA Intern Med. 2017;177:877-878).
So while in theory it is a great concept that screening decisions be made by both the patient and physician and be based on the best available evidence and the patient’s own unique health history, it appears to be easier said than done.
Most of these decisions will be made in primary care practice, and with the time constraints that PCPs are grappling with, along with the need for being up to date on the latest screening data, is this feasible or realistic?
“These discussions can be challenging to incorporate into a busy primary care practice, especially when doctors don’t have the numbers in their head or at the tip of their fingers,” Keating told Medscape Medical News, adding that it can often be easier just to tell women to get screened and to order routine screening for women in their 40s.
PCPs don’t have the time or experience to have the discussion.
Breast cancer specialist Rachel J. Buchsbaum, MD, from Tufts University School of Medicine, Boston, Massachusetts, agreed. “In my experience the discussion of risk-benefit for mammogram is quite complex and PCPs don’t have the time or experience to have the discussion,” she commented. “They send complex screening questions to me,” she told Medscape Medical News.
The PSA Experiment
In 2008, the USPSTF recommended against the use of PSA-based screening for prostate cancer for men younger than 50 years and older than 74 years. In 2012, the group went further and recommended against any PSA-based screening. But, even with these recommendations, US clinicians continue to routinely screen men using the PSA test. As a result, its use has only modestly declined.
Importantly, men who are getting screened are not necessarily discussing it with their physicians, as guidelines recommend.
A recent study reported, for example, that 37.2% of men in 2010 and 37.9% in 2015 received one or more shared decision-making elements, while the percentage of men with recent PSA testing who received at least one shared decision-making element increased nonsignificantly from 58.5% in 2010 to 62.6% in 2015. The change was even lower among men with nonrecent PSA testing (54.6% vs 56.8%, respectively).
“I think many of the problems that primary care physicians face in dealing with prostate cancer screening are likely echoed in the discussions with breast cancer screening, such as they are,” commented Paul Mathew, MD, also from Tufts University School of Medicine, to Medscape Medical News. “I can imagine that it would be difficult for PCPs to be eloquent about the harms and benefits with breast cancer screening given the complexities in the data and the controversies over the magnitude of benefit for the different age groups.”
“PCPs simply don’t have the time, and it’s easier for them to tick a box for the study,” said Mathew. “When organizations recommend shared decision making as a position statement, they rarely take into account how those processes fit into the realities of modern-day practices. Perhaps that is not their responsibility and they must state the position as they see it.”
Decision Tools
The authors suggest that one way of making shared decision making easier is to increase the use of decision tools. Research has demonstrated that these aids can increase knowledge and decrease decisional conflict and anxiety. “Such tools could be provided to patients in advance of visits,” Keating explained, “such as through electronic medical record patient portals.”
This would allow patients time to learn about their individual risk of breast cancer as well as the benefits and harms of mammography screening, and also consider how they feel about the relative benefits and harms, she said. “They can then talk more with their doctor about what might make sense for them.”
“There are tools to help women understand their risk, like the [National Cancer Institute’s] Breast Cancer Risk Assessment Tool and the Breast Cancer Surveillance Consortium Breast Cancer Risk Calculator,” Keating explained, adding that the authors included a list of decision tools in their paper that can help with decisions once risk is understood.
But Mathew pointed out that at least in prostate cancer, decision tools are very underused. “Decision tools were used by less than 5% of physicians in our survey of PCPs that screen for prostate cancer, and I would not be surprised if it is equally low among breast cancer,” he said. “They have demonstrated to be useful under controlled conditions, but very few practices have the bandwidth or intent to adopt them. If they are incentivized to do so, then the situation may change.”
Another expert agreed with the authors that there is a need to promote shared decision making and also risk-based, personalized screening using risk prediction models to help inform decisions. “At the same time, I believe that shared decision making for cancer screening and other health services is extremely difficult to implement in clinical practice, and has largely been unsuccessful due to many practical constraints,” said Paul Han, MD, MPH, director, Center for Outcomes Research & Evaluation and a senior scientist at the Maine Medical Center Research Institute in Portland, who was asked for comment. “And the prospect of adding risk-based screening to the mix makes things even more difficult and complex. This is not to say we shouldn’t try, but we clearly need better approaches.”
The authors, Mathew, Han, and Buchsbaum have disclosed no relevant financial relationships.
JAMA. 2018;319:1814-1815. Abstract
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