Screening mammography works. However, that was not the message promulgated by the U.S. Preventive Services Task Force (USPSTF) in November 2009. The updated guidelines eliminated screening for women younger than age 50 and older than age 74 and suggested biannual screening for women ages 50 to 74. The revision provoked an uproar among radiologists and confusion among women and primary care providers.
Nearly two years after the release of the controversial guidelines, Health Imaging & IT examines their impact on radiology practices, screening mammography volume and women's health. We spoke with breast imagers across the country to determine how they are contending with the new modus operandi in mammography screening.
The volume effect
"Screening mammography volumes are down from 10 to 30 percent across the country," confirms Michael N. Linver, MD, director of mammography at X-Ray Associates of New Mexico in Albuquerque, which has seen screening volume drop 10 to 20 percent since November 2009. Similarly, Scott & White Radiology in Temple, Texas, reports a 25 percent drop-off in screening volumes, shares Debra L. Monticciolo, MD, president of Society of Breast Imaging and breast imaging section chief at Scott & White Radiology.
In fact, Monticciolo believes that the negative impact on screening volume has increased with time. "We saw more of a change in the second year. Women participated in screening in the first year because they were unsure about the guidelines. Now, we are seeing a larger effect."
A survey presented in May at the annual meeting of the American Roentgen Ray Society confirmed the impact of the guidelines on referring physician recommendations. When researchers at the University of Colorado School of Medicine in Denver surveyed 303 primary care physicians about screening practices before and after the release of the guidelines, they found statistically significant decreases in ordering patterns for women ages 40 to 49, according to Jayme Takahashi, MD, a radiology resident at University of Colorado School of Medicine.
Prior to the 2009 guidelines, for patients ages 40 to 49, 56 percent of physicians recommended annual screening mammography, 33 percent recommended biannual screening and 11 percent advised against screening. After the guidelines were revised, 20 percent recommended annual screening, 18 percent recommended biannual screening and 8 percent advised against screening for women in this age group.
Lara A. Hardesty, MD, section chief of breast imaging of University of Colorado Hospital in Denver, devised a related study and examined the effect of guidelines on women seeking mammograms.
Researchers mined institutional mammography databases to calculate the number of women presenting for screening mammograms in the nine months preceding the release of the guidelines (February 2009 to November 2009) and the nine months following the release (November 2009 to August 2010) among women in two age categories: ages 40 to 49 and 50 and older.
Before the guidelines were released, 1,327 women in the age 40 to 49 cohort presented for screening mammography. In the nine months following the release, the number dropped to 1,122, a statistically significant decrease of 15.4 percent. Volume stayed roughly the same for women older than age 50.
The drop is tied to confusion among referring physicians and women. "The guidelines hint that physicians shouldn't be advocating for screening [and suggest] they should wait for patients to initiate the discussion," says Monticciolo. "Anecdotally, women are deciding not to get screened because they interpret the guidelines to mean that they do not need a mammogram until age 50," adds Daniel B. Kopans, MD, director of breast imaging at Massachusetts General Hospital in Boston. Others, says Linver, are confused or trusting enough to defer to the guidelines.
What's more, primary care physicians may be in a bind. "Primary care physicians don't understand the pros and cons of screening," explains Kopans. "They see only two to four women with breast cancer each year. They have to deal with more questions about false positives. Hypertension, heart failure and pneumonia are much bigger problems for them."
But the challenges for primary care physicians extend far beyond clinical understanding and patient care. "What I've heard from my colleagues in primary care is that they feel they need more data from radiologists as to why they should not follow the USPSTF guidelines.