Conflicting Guidelines on Mammograms Can Pose Risks

David B. Troxel, MD, Medical Director, The Doctors Company.

Mammography is an important medical screening test that accounts for more than $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, 10 lives are saved, and for women ages 60 to 69, 42 lives are saved.2 These statistics reflect the fact that breast cancer is more common as women age.3 However, screening guidelines issued by national organizations and medical specialties have inconsistent recommendations about screening ages and intervals,4 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.

Guidelines for screening mammography vary. The American Cancer Society now recommends initiation of mammography at age 45, followed by annual screening until age 55 then biennial thereafter. This recommendation varies from all the others that preceded it.

A large body of literature supports screening for women aged 50–70 with a decrease in breast cancer mortality. Recommendations for the duration of routine screening vary.

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.5 Looking beyond inconsistency in national guidelines, it is critical that screening recommendations be congruent within a practice or group. Situations in which the radiologist recommends annual screening and clinicians prefer biennial testing can create a medical record with contradictions readily exploited by a plaintiff’s attorney.

One the very best discussions of screening mammography guidelines is to be found in UptoDate.6

Adding to this dilemma is that some states are now requiring physicians to notify women who have dense breast tissue,7 which makes it more difficult to read mammograms. However, there are no universal 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.8 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.


References

  1. 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.
  2. Pace LE, Keating NL. A systematic assessment of benefits and risks to guide breast cancer screening decisions. JAMA. 2014;311(13):1327-1335.
  3. Mammography: Benefits, risks, what you need to know. BreastCancer.org. http://www.breastcancer.org/symptoms/testing/types/mammograms/benefits_risks.
  4. 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.
  5. Ibid
  6. Elmore JG. Screening for breast cancer: strategies and recommendations. Aronson MD, Malin JA, eds. UpToDate. Waltham, MA: UpToDate Inc. www.uptodate.com/contents/screening-for-breast-cancer-strategies-and-recommendations.
  7. Rabin, R. Dense breasts may obscure mammogram results. New York Times. June 16, 2014. http://well.blogs.nytimes.com/2014/06/16/dense-breasts-may-obscure-mammogram-results/?_php=true&_type=blogs&_r=0.
  8. Mammography. RadiologyInfo.org. Feb 3, 2017. http://www.radiologyinfo.org/en/info.cfm?pg=mammo.

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 considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

J11607 06/18

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