Current guidelines
Breast cancer is the second leading cause of cancer death among women in United States . In a departure from current guidelines, the most recent update of United States Preventive Services Task Force (USPSTF) recommends biennial screening film mammography for women age 50–74 years. For women age 40–49 years, no recommendation for screening is made; rather, the decision is left to the individual woman and her physician. Finally, there is no recommendation for screening in women 75 years of age or older because of insufficient evidence to assess the additional benefits and harms of screening mammography . This update was based on a new systematic review investigating “mortality” and “life year gained” with the implementation of screening mammography in women age 40–49 years and assessing the benefit of screening versus the harms (eg, a higher false-positive result rate) in this age group . Furthermore, they concluded that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination, digital mammography, or magnetic resonance imaging as other screening modalities for breast cancer .
The controversy
The USPSTF guidelines openly conflict with and have not been endorsed by the American Cancer Society . If belief in a particular set of breast cancer screening recommendations were a religion, we are agnostics. More important, however, it is the woman’s perception of the conflicting guidelines that ultimately drives her screening behavior. The uncertainty and ambiguity about mammography recommendations, even among experts, can lead to increased perceived cancer risk, cancer-related worry, and decreased perceived cancer preventability among patients ; in this case, diminished uptake of mammography over time and lower intention for future mammography . Further, a multiplicity of guidelines can lead to confusion over which guideline to follow independent of any cancer-related concerns. Despite conflicting recommendations, common across the guidelines is the emphasis on patient-physician communication to help women understand the risks and benefits and to make sure their decisions align with their values. Radiologists must understand the process of shared decision-making requiring elicitation of patient preferences particularly in sensitive health decisions (eg, breast cancer screening) to meet the emerging demand for increased radiologist participation in clinical care. Effective communication of the ambiguous or conflicting information in cancer control may increase a patient’s compliance with cancer screening initiation and maintenance.
Patient preferences for screening
Patients have individual preferences for different tests, varying levels of knowledge, different estimates of risk or susceptibility, and varying attitudes toward health risks and different risk taking behaviors. They have different beliefs regarding their health being controlled by themselves or others (eg, health care providers, family members, supernatural entity) . There are cultural or ethnic variations in attitudes towards health and disease (eg, mammography underutilization in African-American women because of race-based medical mistrust or a strong belief in chance and the inevitability of disease, in addition to financial barriers) . Additionally, their own or friends’ previous experience with a screening test or a screening center may affect their attendance and compliance (ie, ease of test administration and comfort, its complications, side effects, cost, and cost effectiveness, the waiting time for results, the availability of screening center and appropriate appointment times, female staff and finally the psychological harms associated with the test itself as well as those associated with waiting for test results, or having a false-positive result) . All of these factors contribute to women’s decisions regarding whether to undergo mammography. A recent study showed that screening mammography utilization was reported to be 41%–50% among an insured population of 40–85-year-old women . This low level of adherence among insured women is concerning and it is possible that increased shared decision-making by radiologists or other improvements to the mammography experience could raise those rates.
Unintended consequences of screening
False-positive results, a possible consequence of breast cancer screening, may occur in up to 8% in different women age groups who are undergoing either film or digital mammography screening . Having a false-positive mammogram may result in psychological, behavioral, and economic impacts, including a short-term increase in generalized and breast cancer–specific distress and anxiety , a long-term impact on the perception of increased cancer risk and severity, and awareness of one’s mortality , a breast and non–breast related health care hyperutilization , and a varying attitude toward breast screening test utilization among women in United States. The potential psychological harms, and unnecessary imaging tests and biopsies for women with false-positive mammograms, as well as the lower reduction in breast cancer–related mortality with mammography in women age 40–49 years were the main reasons for USPSTF to recommend against routine screening mammography in women age 40–49 years, leaving the decision to undergo mammography to the individual patient and her doctor .
Although it is clear that false-positive screening test results can have great psychological, behavioral, and economic impacts, the degree of impact of these results (real or perceived) on a woman’s health-related quality of life (QOL) is less clear. Systematic differences in valuation of health-related QOL by patients and general public, which the Beaver Dam Health Outcomes study has illustrated, create difficulties for policy makers . Complicating the issue for false-positive mammography is the absence of accurate data on QOL burden attributed to individuals experiencing a false-positive screening test. This has not been studied to date, nor have the implications on attendance at initial and follow-up screening mammography been elucidated.
Another possible consequence of breast cancer screening is overdiagnosis of invasive and noninvasive breast cancers that are unlikely to become clinically evident during the patients’ lifetime. Estimates of overdiagnosis have varied from as high as one in three breast cancers detected to as low as 1% of all tumors diagnosed in a population offered organized screening . Evans et al suggest that the issue of overdiagnosis has been overstated and prognostic indicators can accurately predict the detected lesions outcome .
Patient-physician communication
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Radiologist’s role as a physician
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Radiologist-patient communication: Traditional and emerging methods
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Designing the optimum radiology center
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Conclusion
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