Original Article

Factors Associated with Routine Recommendation of Mammography for Women Aged 40–49: Provider Characteristics and Screening Influences

Authors: Kathryn A. Martinez, PhD, MPH, Abhishek Deshpande, MD, PhD, Allison L. Ruff, MD, Shari D. Bolen, MD, MPH, Kathryn Teng, MD, Michael B. Rothberg, MD, MPH

Abstract

Objectives: Despite the US Preventive Services Task Force recommendation against screening mammography in women younger than 50 years, rates remain high, suggesting that screening recommendations may be motivated by other factors. The objective of this study was to understand provider-reported influences on screening recommendations for women 40 to 49 years old at average risk for breast cancer.

Methods: An online survey of primary care providers was conducted at four health centers in Cleveland, Ohio in 2015. Provider-reported routine recommendation of mammography for women aged 40 to 49 at average risk for breast cancer was the primary outcome. The independent measures included influence of electronic health records, national guidelines, institutional policy, patient preferences, concerns about overtreatment, concerns about false-positives, and interest in early detection on screening recommendations. We used multivariable logistic regression to estimate the odds of recommending screening by potential influences, controlling for provider characteristics and provider-assessed balance of harms and benefits of screening in this age group.

Results: Of 612 providers invited, 220 completed the survey (response rate 36%); 69% routinely recommended screening and 24% believed that the harms of screening in younger women outweighed the benefits. Being influenced by institutional policy was associated with higher odds of recommending screening (odds ratio [OR] 4.19, 95% confidence interval [CI] 1.35–12.9), as was interest in early detection (OR 4.19, 95% CI 1.31–12.9). Conversely, strong influence of national guidelines was associated with a lower odds of recommending screening (OR 0.25, 95% CI 0.09–0.71). The influence of patient preferences was not associated with screening recommendation.

Conclusions: Providers face competing influences on screening recommendations for younger patients, some of which may be at odds with their beliefs. Institutional policy change allowing individually tailored screening discussions may improve patient-centered care.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA Cancer J Clin 2015;65:5-29.
 
2. Berry DA, Cronin KA, Plevritis SK, et al. Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 2005;353:1784-1792.
 
3. Carney PA, Miglioretti DL, Yankaskas BC, et al. Individual and combined effects of age, breast density, and hormone replacement therapy use on the accuracy of screening mammography. Ann Intern Med 2003;138:168-175.
 
4. Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med 2012;367:1998-2005.
 
5. Miller AB, Wall C, Baines CJ, et al. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ 2014;348:g366.
 
6. Welch HG, Passow HJ. Quantifying the benefits and harms of screening mammography. JAMA Intern Med 2014;174:448-454.
 
7. Department of Health and Human Services. Breast cancer screening for women ages 40-49. https://consensus.nih.gov/1997/1997BreastCancerScreening103html.htm. Accessed August 8, 2016.
 
8. US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009;151:716-726., W-236.
 
9. Sawaya GF, Guirguis-Blake J, LeFevre M, et al. Update on the methods of the U.S. Preventive Services Task Force: estimating certainty and magnitude of net benefit. Ann Intern Med 2007;147:871-875.
 
10. Siu AL, , 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.
 
11. 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.
 
12. Dehkordy SF, Hall KS, Roach AL, et al. Trends in breast cancer screening: impact of U.S. Preventive Services Task Force recommendations. Am J Prev Med 2015;49:419-422.
 
13. Wang AT, Fan J, Van Houten HK, et al. Impact of the 2009 US Preventive Services Task Force guidelines on screening mammography rates on women in their 40s. PLoS One 2014;9:e91399.
 
14. Block LD, Jarlenski MP, Wu AW, et al. Mammography use among women ages 40-49 after the 2009 U.S. Preventive Services Task Force recommendation. J Gen Intern Med 2013;28:1447-1453.
 
15. Yabroff KR, Zapka J, Klabunde CN, et al. Systems strategies to support cancer screening in U.S. primary care practice. Cancer Epidemiol Biomarkers Prev 2011;20:2471-2479.
 
16. Scott A, Sivey P, Ait Ouakrim D, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst Rev 2011;9:CD008451.
 
17. Baron RC, Melillo S, Rimer BK, et al. Intervention to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers a systematic review of provider reminders. Am J Prev Med 2010;38:110-117.
 
18. Yasmeen S, Romano PS, Tancredi DJ, et al. Screening mammography beliefs and recommendations: a Web-based survey of primary care physicians. BMC Health Serv Res 2012;12:32.
 
19. Kadivar H, Goff BA, Phillips WR, et al. Nonrecommended breast and colorectal cancer screening for young women: a vignette-based survey. Am J Prev Med 2012;43:231-239.
 
20. Meissner HI, Klabunde CN, Han PK, et al. Breast cancer screening beliefs, recommendations and practices: primary care physicians in the United States. Cancer 2011;117:3101-3111.
 
21. Miller JW, Baldwin LM, Matthews B, et al. Physicians’ beliefs about effectiveness of cancer screening tests: a national survey of family physicians, general internists, and obstetrician-gynecologists. Prev Med 2014;69:37-42.
 
22. Haas JS, Sprague BL, Klabunde CN, et al. Provider attitudes and screening practices following changes in breast and cervical cancer screening guidelines. J Gen Intern Med 2016;31:52-59.
 
23. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)-a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377-381.
 
24. US Senate and House of Representatives. Patient Protection and Affordable Care Act. https://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf. Accessed November 16, 2016.
 
25. Barry MJ, Edgman-Levitan S. Shared decision making-pinnacle of patient-centered care. N Engl J Med 2012;366:780-781.
 
26. Oeffinger KC, Fontham ET, Etzioni R, et al. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA 2015;314:1599-1614.
 
27. Gunn CM, Soley-Bori M, Battaglia TA, et al. Shared decision making and the use of screening mammography in women younger than 50 years of age. J Health Commun 2015;20:1060-1066.
 
28. Corbelli J, Borrero S, Bonnema R, et al. Physician adherence to U.S. Preventive Services Task Force mammography guidelines. Womens Health Issues 2014;24:e313-e319.
 
29. Corbelli J, Borrero S, Bonnema R, et al. Differences among primary care physicians’ adherence to 2009 ACOG guidelines for cervical cancer screening. J Womens Health (Larchmont) 2014;23:397-403.
 
30. Yabroff KR, Saraiya M, Meissner HI, et al. Specialty differences in primary care physician reports of Papanicolaou test screening practices: a national survey, 2006 to 2007. Ann Intern Med 2009;151:602-611.
 
31. Han PK, Klabunde CN, Breen N, et al. Multiple clinical practice guidelines for breast and cervical cancer screening: perceptions of US primary care physicians. Med Care 2011;49:139-148.
 
32. Allen SV, Solberg Nes L, Marnach ML, et al. Patient understanding of the revised USPSTF screening mammogram guidelines: need for development of patient decision aids. BMC Womens Health 2012;12:36.
 
33. Allen JD, Bluethmann SM, Sheets M, et al. Women’ responses to changes in U.S. Preventive Task Force’ mammography screening guidelines: results of focus groups with ethnically diverse women. BMC Public Health 2013;13:1169.
 
34. Morris E, Feig SA, Drexler M, et al. Implications of overdiagnosis: impact on screening mammography practices. Popul Health Manag 2015;18( Suppl 1 ):S3-S11.
 
35. Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst 2010;102:605-613.
 
36. Harding C, Pompei F, Burmistrov D, et al. Breast cancer screening, incidence, and mortality across US counties. JAMA Intern Med 2015;175:1483-1489.
 
37. Ernster VL, Ballard-Barbash R, Barlow WE, et al. Detection of ductal carcinoma in situ in women undergoing screening mammography. J Natl Cancer Inst 2002;94:1546-1554.
 
38. Welch HG, Woloshin S, Schwartz LM. The sea of uncertainty surrounding ductal carcinoma in situ-the price of screening mammography. J Natl Cancer Inst 2008;100:228-229.
 
39. Narod SA, Iqbal J, Giannakeas V, et al. Breast cancer mortality after a diagnosis of ductal carcinoma in situ. JAMA Oncol 2015;1:888-896.
 
40. Esserman L, Yau C. Rethinking the standard for ductal carcinoma in situ treatment. JAMA Oncol 2015;1:881-883.
 
41. Esserman LJ, Thompson IM, Jr Reid B. Overdiagnosis and overtreatment in cancer: an opportunity for improvement. JAMA 2013;310:797-798.
 
42. Voss JD, Schectman JM. Prostate cancer screening practices and beliefs. J Gen Intern Med 2001;16:831-837.
 
43. Hall IJ, Taylor YJ, Ross LE, et al. Discussions about prostate cancer screening between U.S. primary care physicians and their patients. J Gen Intern Med 2011;26:1098-1104.
 
44. Ubel PA, Asch DA. Creating value in health by understanding and overcoming resistance to de-innovation. Health Aff (Millwood) 2015;34:239-244.
 
45. Cunningham CT, Quan H, Hemmelgarn B, et al. Exploring physician specialist response rates to Web-based surveys. BMC Med Res Methodol 2015;15:32.