Breast cancer is currently the second greatest cause of cancer-related death in women living in the United States, with approximately 40,000 women dying annually from complications of breast cancer.1 As a result of both earlier detection through screening mammography and the benefits of adjuvant systemic therapies, the mortality rate due to breast cancer has decreased over the past 25 years.2 Nonetheless, considerable professional disagreement exists over the most appropriate age at which to begin routine screening mammograms and how frequently they should be performed. As a landmark event in this ongoing debate, the U.S. Preventive Services Task Force (USPSTF) released updated guidelines for screening mammograms in 20093 that differed significantly both from their own prior recommendations and from those of other major national health care organizations and advocacy groups. Specifically, the recommended age at which to initiate routine breast cancer screening in women was increased from 40 to 50 years, with the recommendation that the decision to refer women in their 40s for screening be based on shared decision-making (ie, a discussion of the risks and benefits of screening between physician and patient). In addition, the recommended frequency of screening in the 50- to 75-year-old female patient population was changed from annual to biannual. In contrast, NCCN and the American Congress of Obstetricians and Gynecologists continued to recommend that routine screening be initiated at age 40 years and that screening be performed annually at least until age 75 years, as did the American Cancer Society (ACS) until their recent guideline revision in October 2015,4–6 with the ACS more recently recommending routine screening begin at age 45 years, be performed annually between the ages of 45 and 55 years, and thereafter be performed biannually. With the updated USPSTF guidelines released in January 2016 being essentially unchanged from those released in 2009,7 significant differences between national organization guidelines remain.
Although the earliest studies investigating the impact of the 2009 USPSTF screening mammography guidelines did not detect a decrease in screening rates following their release,8,9 a later and much larger study based on data from 5.5 million women found that among non-black women, 2012 screening rates were 6% to 17% lower, depending on age and race category, than projections based on screening that occurred between 2005 and 2009.10 Furthermore, in differing substantially from those of other national medical and cancer advocacy groups, the 2009 USPSTF guidelines increased the potential for differences in screening mammogram use by patients of different provider subgroups. Differences in patient screening mammography rates based on medical provider characteristics such as gender, age, subspecialty, or professional degree have long been noted,11,12 observations that may reflect a combination of provider subgroup differences in attitude toward screening mammography efficacy, patient attitudes towards screening that correlate with preference for a female provider, and a tendency for female providers to provide more preventive care in general than their male counterparts, with inconsistent findings across studies.13,14 Discordant clinical practice guidelines inherently foster greater variation in provider clinical practice, because providers rely more heavily on their individual judgment in interpreting data supporting conflicting guidelines, and ultimately in clinical decision-making, thereby increasing the potential for systematic variation in care. Introducing a recommendation for informed decision-making between providers and their patients in place of routine referral further increases the potential impact of differences in provider attitudes and practice on patient care.
Less established is whether a relationship exists between provider level of training and patient screening mammography rates. Given the nascent clinical practice of resident physicians, it was hypothesized that this group might adopt new screening guidelines more readily than their attending physician counterparts. Patterns of clinical practice by this group are of particular interest as they predict, albeit imperfectly, future medical practice.
For these reasons, patient screening mammography rates for internist subgroups defined by gender and level of training were determined in the 2 years before and 2 years after the release of the 2009 USPSTF clinical practice guidelines, to investigate how any preexisting differences may have changed following their release.
National Cancer Institute. Surveillance Epidemiology and End Results (SEER). SEER Stat Fact Sheets: Breast. Available at: http://seer.cancer.gov/statfacts/html/breast.html. Accessed June 1, 2015.
Berry DA, Cronin KA, Plevritis SKCancer Intervention and Surveillance Modeling Network (CISNET) Collaborators. Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 2005;353:1784–1792.
United States Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009;151:716–726.
Bevers TB, Helvie M, Bonaccio E. NCCN Clinical Practice Guidelines in Oncology: Breast Cancer Screening and Diagnosis. Version 1.205. Accessed June 1, 2015. To view the most recent version of these guidelines, visit NCCN.org.
American College of Obstetricians-Gynecologists. Practice bulletin no. 122: Breast cancer screening. Obstet Gynecol 2011;118(2 Pt 1):372–382.
American Cancer Society Guidelines for the Early Detection of Cancer. Available at: http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer. Accessed January 17, 2016.
Sui ALon behalf of the U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2016;164:279–296.
Howard DH, Adams EK. Mammography rates after the 2009 US Preventive Services Task Force breast cancer screening recommendation. Prev Med 2012;55:485–487.
Pace LE, He Y, Keating NL. Trends in mammography screening rates after publication of the 2009 US Preventive Services Task Force recommendations. Cancer 2013;119:2518–2523.
Wharam J, Landon B, Zhang F. Mammography rates 3 years after the 2009 US Preventive Services Task Force Guidelines changes. J Clin Oncol 2015;33:1067–1074.
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Hall JA, Palmer RH, Orav EJ. Performance quality, gender, and professional role: a study of physicians and nonphysicians in 16 ambulatory care practices. Med Care 1990;28:489–501.
Henderson J, Weisman C. Physician gender effects on preventive screening and counseling: an analysis of male and female patients' health care experiences. Med Care 2001;39:1281–1292.
Kerfoot B, Holmberg E, Lawler E. Practitioner-level determinants of inappropriate prostate-specific antigen screening. Arch Intern Med 2007;167:1367–1372.
Ramirez AG, Wildes KA, Napoles-Springer A. Physician gender differences in general and cancer-specific preventions attitudes and practices. J Cancer Educ 2009;24:85–93.
Stacey D, Bennett CL, Barry MJ. Decision aids for people facing health treatment or screening decisions. Cochrane Database Sust Rev 2014;1:CD001431.
Brawley O, Byers T, Chen A. New American Cancer Society process for creating trustworthy cancer screening guidelines. JAMA 2011;306:2495–2499.