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Editorial: Radiologists Have Opportunities to Improve Patient Engagement in Mammographic Screening

Key findings

  • Despite the contradictions between breast cancer screening guidelines, radiologists have opportunities to improve patient engagement in mammographic screening
  • One strategy is to emphasize the areas of agreement across guidelines: that screening mammography is a critically important screening test
  • Another strategy is for radiologists to work with oncologists and epidemiologists to move the field towards a more precise, risk-based screening

In 2017, the American College of Radiology and the Society of Breast Imaging reaffirmed their support for starting annual screening mammography at age 40. The organizations based their recommendation on randomized control trials and modeling studies that have shown the greatest reductions in breast cancer mortality, even among women in their 40s, by starting at that age.

Last year, the American College of Physicians (ACP) evaluated the quality and content of seven breast cancer screening guidelines. Its decision, similar to U.S. Preventive Services Task Force (USPSTF) guidelines, was to recommend biennial mammography for average-risk women starting at age 50. For women between 40 and 49 years old, the ACP recommends that clinicians discuss patients' preferences with them, along with the harms and benefits of starting mammographic screening.

In an editorial in the Journal of the American College of Radiology, Anand K. Narayan, MD, PhD, faculty in the Division of Breast Imaging in the Department of Radiology at Massachusetts General Hospital, and Constance D. Lehman, MD, PhD, director of the Division of Breast Imaging, propose how radiologists can improve patient engagement in breast cancer screening given the contradictions in guidelines. This summary covers two of their suggestions: discuss areas of agreement across guidelines and work as a profession to improve breast cancer risk models.

Emphasize Areas of Agreement

Some journalists responded to the ACP announcement by saying women can opt out of mammography altogether. No major organization has suggested that is reasonable—all agree mammography is a critically important screening test. Radiologists should make sure patients, referring providers and health care administrators understand that.

Other topics of strong agreement are:

  • More lives are saved by screening women in their 40s than by waiting
  • Breast cancers diagnosed before age 50 are more likely to be biologically aggressive and have poor prognoses
  • There are potential harms of screening mammography

The principal potential harm, according to the USPSTF, is overtreatment of nonlethal breast cancers. Studies consistently demonstrate that this is a real phenomenon, although the estimated incidence ranges widely from 3% to 42%. Modeling studies show that the age of starting mammography has minimal impact on the proportion of overdiagnosed and treated cases.

The other harm, according to the USPSTF, is the anxiety caused by false-positives. This is short-term, though, as documented in the Digital Mammographic Imaging Screening Trial. That study also found false-positives had no effect on long term health-related quality of life while increasing women's intentions to continue mammographic screening.

Improve Risk Models

Age-based approaches to screening are limited, but about 75% of women who develop breast cancer have no apparent personal or family risk factors, as reported in the American Journal of Public Health. Therefore, existing breast cancer risk models are poorly predictive.

Radiologists are uniquely situated to address this problem. At mammography centers, millions of women list their breast cancer risk factors and find out if they have dense breast tissue. By harnessing this data, radiologists could improve the performance of risk models and perhaps move the field from the limited age-based approach to a more precise, risk-based screening.

Already, breast imagers and computer scientists have developed an artificial intelligence–based risk model that combines mammography results with information about risk factors, reported in Radiology. Developed by an Mass General- and MIT-based team of researchers, this risk model has been shown to outperform conventional models, particularly for Black women.

Breast imagers should also ensure they have leadership roles in conversations about risk-based screening and resist efforts to reduce access to breast cancer screening based on inadequate risk prediction algorithms.

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