Conflicting Guidelines on Screening Mammography Can Pose Risks

David B. Troxel, MD, Medical Consultant to The Doctors Company

Mammography is an important medical screening test. An analysis of age-adjusted female breast cancer mortality rates from the National Cancer Institutes Surveillance, Epidemiology, and End Results (SEER) program concluded that since 1989, between 384,000 and 614,500 breast cancer deaths have been averted through the use of mammography screening and improved treatment.1

Unfortunately, screening guidelines issued by national organizations and medical specialties contain inconsistent recommendations about screening ages and intervals, which can cause delayed or missed diagnoses. The tabular summary of seven Breast Cancer Screening Guidelines for Women from the Centers for Disease Control and Prevention effectively illustrates these inconsistencies.

As documented in claims closed by The Doctors Company, misdiagnosis, delayed diagnosis, and failure to diagnose breast cancer are liability risks—particularly for radiologists, gynecologists, general surgeons, and family medicine physicians. Many factors contribute to these claims but among them are:

  • Conflicting screening guideline recommendations.
  • False negative mammograms, which fail to detect some cancers.
  • False positive mammograms, which lead to breast biopsy.

The American Cancer Society now recommends that the decision to start screening mammography annually should be discussed with women ages 40 through 44 and that women ages 45 through 49 should be screened annually as should women ages 50 through 54. Women 55 years of age and older should transition to biennial screening or have the opportunity to continue screening annually.

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. Looking beyond inconsistency in national guidelines, adhering to the screening paradigm chosen is more important than which specific guideline is used, and it is critical that screening recommendations be congruent within a medical practice or group. Situations in which the radiologist recommends annual screening and clinicians prefer biennial testing or to adopt different guidelines within the practice can create a medical record with contradictions readily exploited by plaintiffs’ attorneys.

Adding to this dilemma is that some states require physicians to notify women who have dense breast tissue. Dense breast tissue, which makes reading and interpreting mammograms more difficult, occurs in about 50 percent of women over age 40. 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 mammographic appearance. Physicians should consider a personalized approach that best assesses the individual patient’s needs.

Patient Safety Strategies

Physicians can reduce risks and promote patient safety by following these strategies:

  • Communicate with patients about conflicting guideline recommendations.
  • Discuss why you believe your recommendation is right for the patient.
  • Review the patient’s breast-related medical history and breast cancer risk factors to assess the impact on breast cancer risk.
  • Ensure that you have a comprehensive follow-up system for mammogram reports in place.
  • Clearly communicate mammogram test results to the patient in a timely manner, and ensure that the patient understands the significance of the findings and recommendations.
  • Document all discussions with patients in the medical record.
  • Reach agreement with all members of your medical group or practice to follow the same guidelines for breast cancer screening.

For additional assistance, please contact the Department of Patient Safety and Risk Management at (800) 421-2368 or patientsafety@thedoctors.com.


Reference

  1. Hendrick RE, Baker JA, Helvie MA. Breast cancer deaths averted over 3 decades. Cancer. 2019;125(9):1482-1488. Published May 1, 2019. doi:10.1002/cncr.39154

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.

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