The current issue of Communique, a two-page quarterly newsletter published by Abbott Northwestern Hospital’s Piper Breast Center, contains a sentence that took me by surprise.
It was in the cover article about the updated breast-cancer screening guidelines from the U.S. Preventive Services Task Force (USPSTF).
Those are the guidelines that caused the huge public hullabaloo last fall because they said that most women don’t need routine mammograms until age 50 and that a mammogram every other year is sufficient after that.
Although the guidelines recommend against routine mammograms for women aged 40 to 49, they don’t say women should be restricted from having them. Instead, the Task Force encourages “individualized informed decision making about when to start mammography screening” — decision making that includes a full understanding of the potential harms as well as the potential benefits of such screening.
As the Task Force’s vice-chair, Dr. Diana Petitti, said a few days after the guidelines were released: “So, what does this mean if you are a woman in your 40s? You should talk to your doctor and make an informed decision about whether mammography is right for you based on your family history, general health and personal values.”
A futile discussion?
The Communique article, however, seems to be telling women — or at least those under age 50 — not to bother talking about whether they need screening with their primary care physicians.
“At the Piper Breast Center,” wrote Dr. Deborah Day, the center’s medical director and chief radiologist, “we … do not agree with USPSTF’s recommendation that — rather than undergo routine screening — this group of women should discuss the need for screening with their health care providers. Since 75-80 percent of women with newly diagnosed breast cancer have no known risk factors, it will be difficult for providers to determine who should be screened and who should not.”
I called Day to ask her if I was reading that statement correctly: Was she telling women aged 40 to 49 to not discuss the pros and cons of undergoing routine mammograms with their primary care doctors?
The statement is particularly confusing, I noted, because at the end of the article she tells women “to talk to your health care provider about your family health history and any concerns you might have.”
Which is it? Should or shouldn’t women talk with their doctors about routine screening?
“I guess that didn’t come out exactly the way I was meaning it to,” Day told me.
“I’m not saying they shouldn’t discuss it with their doctor,” she said. But she doesn’t see much benefit in that discussion, she added, because “it’s hard to tell who’s at risk [for breast cancer]. Talking about risk is kind of futile unless you’re at high risk.”
Day said she believes strongly that all women aged 40 and older should just go ahead and be screened annually.
A different view
Dr. Patricia Fontaine, president of the Minnesota chapter of the American Academy of Family Physicians, sees things a bit differently (although she was quick to tell me that she admires Dr. Day and the care offered women at the Piper Breast Clinic.)
As Fontaine’s organization notes on its national website, family physicians are “uniquely positioned to help women make decisions about screening, as well as about other aspects of health management.”
“There is nobody who knows you better and nobody who really wants the same thing for you as you want for yourself,” Fontaine told me. “I don’t think your primary care provider is going to be pushing an agenda one way or the other.”
The USPSTF (an independent panel of experts that assesses the scientific evidence for a variety of preventive health services) is “very hard to convince when it come to procedures,” she said. “They have to have firm and fast evidence that the benefit exceeds the harm before they recommend it.”
Sometimes, Fontaine said, she recommends USPSTF guidelines to her patients, and “sometimes I recognize that there is something I may want to be able to do for my patients that may not be fully supported by their guidelines.”
“My goal is not to convince women not to have mammograms,” she added. “I think that if a woman wants to have a mammogram for peace of mind, she should be able to.”
But other women, Fontaine pointed out, may decide not to be screened annually — or at all before the age of 50. “Every woman is different,” said Fontaine, “not only in her risk factors, but in her psychological makeup.”
You can read the American Academy of Family Physcians’ updated recommendations for breast cancer screening, which essentially follow those of the USPSTF, here. And you can read Day’s Communique article responding to the USPSTF’s recommendations here [PDF].