Conflicting Guidelines on Mammograms Can Pose Risks
Mammography is an important medical screening test that accounts for $8 billion in annual healthcare expenditures in the United States.1 For every 10,000 women ages 40 to 49 who receive regular mammograms, five lives are saved by the discovery of cancers that otherwise would go undetected. For women ages 50 to 59, ten lives are saved, and for women ages 60 to 69, 42 lives are saved. These statistics reflect the fact that breast cancer is more common as women age.2 However, screening guidelines issued by national organizations and medical specialties have inconsistent recommendations about screening ages and intervals,3 which can cause delayed or missed diagnoses.
Misdiagnosis, delayed diagnosis, and failure to diagnose breast cancer are liability risks, particularly for radiologists, gynecologists, general surgeons, and family medicine practitioners, according to closed claims data from The Doctors Company from 2007–2013. Several factors contribute to these risks:
- Conflicting guideline screening recommendations.
- False negative mammograms, which fail to detect some cancers.
- False positive mammograms, which lead to breast biopsy.
- Radiation exposure.
The 2008 American College of Radiology and 2003 American Cancer Society guidelines recommend annual mammography screening for asymptomatic, average-risk women age 40 and older.4 However, the guidelines set forth by the U.S. Preventive Services Task Force in 2009 recommend starting routine mammograms for women with an average risk of breast cancer at age 50.4 Although the presence of numerous professionally endorsed options arguably gives physicians a broader set of clinically valid choices, inconsistent guidelines may also leave physicians feeling more exposed to malpractice claims.3
Adding to this dilemma is that some states are now requiring physicians to notify women who have dense breast tissue,5 which makes it more difficult to read mammograms. However, there are no guidelines on what physicians should do if a woman has dense breast tissue.
In addition, interpreting mammograms can be difficult because normal breasts vary in their mammographic appearance.6 Physicians should consider a personalized approach that best assesses the individual patient’s need.
Physicians can reduce risks and promote patient safety by:
- Communicating with patients about conflicting guideline recommendations.
- Discussing why you believe your recommendation is right for the patient.
- Reviewing the patient’s breast-related medical history and breast cancer risk factors to assess their impact on breast cancer risk.
- Ensuring that an adequate follow-up system for mammogram reports is in place.
- Clearly communicating mammogram test results to the patient in a timely manner and ensuring that the patient understands the significance of the findings and recommendations.
- Documenting all discussions with patients in the medical record.
For medical groups, all member physicians should agree on and follow consistent practice guidelines for breast cancer screening.
- Steere A. Mammography cost varies by $8 billion annually, controversy ensues. Health Imaging. February 5, 2014. http://www.healthimaging.com/topics/womens-health/mammography-cost-varies-8-billion-annually-controversy-ensues. Accessed May 30, 2014.
- Mammography: Benefits, risks, what you need to know. BreastCancer.org. March 25, 2014. http://www.breastcancer.org/symptoms/testing/types/mammograms/benefits_risks. Accessed May 30, 2014.
- Kachalia A, Mello M. Breast cancer screening: Conflicting guidelines and medicolegal risk. JAMA. 2013;309(24):2555-2556. http://jama.jamanetwork.com/article.aspx?articleid=1691914. Accessed May 30, 2014.
- Pace L, Keating N. A systematic assessment of benefits and risks to guide breast cancer screening decisions. JAMA. 2014;311(13):1327-1335. http://jama.jamanetwork.com/article.aspx?articleid=1853165. Accessed May 30, 2014.
- Rabin, R. Dense breasts may obscure mammogram results. New York Times. June 14, 2014. http://well.blogs.nytimes.com/2014/06/16/dense-breasts-may-obscure-mammogram-results/?_php=true&_type=blogs&_r=0. Accessed June 23, 2014.
- Mammography. RadiologyInfo.org. May 7, 2013. http://www.radiologyinfo.org/en/info.cfm?pg=mammo. Accessed May 30, 2014.
By David B. Troxel, MD, Medical Director, The Doctors Company.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.