Opinion
EDITORIAL
Physician Adherence to Breast Cancer
Screening Recommendations
Deborah Grady, MD, MPH; Rita F. Redberg, MD, MSc
We found the Research Letter by Radhakrishnan et al1 rather
dispiriting. It suggests that a large proportion of primary care
physicians recommend screening mammography for women
who are more likely to expe-
rience harms than benefits
Related articles
from the examination. Ow-
ing to the greater chance of harm, neither the American Can-
cer Society nor the US Preventive Services Task Force (USPSTF)
recommend routine screening mammography for women ages
40 to 44 years. Despite this, 81% of the primary care physi-
cians surveyed in this study reported that they recommend
mammography to women in this age range.
In our view, the most evidence-based, transparent, and
conflict-free guidelines are from the USPSTF. The USPSTF rec-
ommends routine biannual screening mammography for
women between the ages of 50 and 74 years.2 However, 88%
of physicians in this study recommended routine mammog-
raphy for women ages 45 to 50 years and 67% recommended
mammography for women 75 and older. In addition, physi-
cians inexplicably trusted other guidelines more than the
USPSTF, which is publicly funded, uses strict methods, and
carefully supports recommendations with evidence. Perhaps
those who responded to this online survey of a random sample
from the American Medical Association Physician Masterfile
are not representative of US primary care physicians in gen-
eral. But we doubt that these estimates could be biased enough
to change the conclusion that US physicians, in large num-
bers, do not follow evidence-based guidelines and continue
to recommend screening mammography to women who are
more likely to be harmed than to benefit. It is estimated that
50% of women who undergo 10 mammography screens will
have a false-positive finding.3 False-positive mammogram re-
sults lead to unnecessary anxiety; additional testing, includ-
ing repeat mammograms and other breast imaging, such as
breast magnetic resonance imaging, which are uncomfort-
able, painful, and time-consuming; unneeded procedures, such
as biopsies; and overdiagnosis of indolent tumors that would
never have become bothersome.
Why Do Physicians Overuse Mammography?
There have been many explanations over the years for why phy-
sicians perform tests and procedures for which there is no evi-
dence of benefit—or in this case, where there is actual evi-
dence of harm. One important issue is that payment systems
in the United States typically reward ordering tests and pro-
cedures over taking the time to talk to patients about risks and
benefits. The fear of litigation is often mentioned as a reason
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for unnecessary testing. Other excuses range from the influ-
ence of many decades of hype in the general and medical me-
dia, the idea that early treatment must be good, that knowing
is better than not knowing, the allure of doing something rather
than nothing, and the conviction that patients like more test-
ing. We believe there is also a common belief among physi-
cians and patients that it is good and a sign of caring to go
beyond what is recommended for their patients—thereby ex-
tending the use of tests that are beneficial for higher-risk pa-
tients to lower-risk patients where harm outweighs benefit. We
believe that when physicians say they are doing what pa-
tients want when ordering unnecessary testing, we are fail-
ing to acknowledge that patients usually want what we as phy-
sicians tell them is good for them. However, at least some
physicians are inaccurately advising women that mammo-
grams at age 40 can save lives and are not offering any in-
formed discussion of risks and benefits.4
We do not believe that if we told women 50 years or
younger that mammograms are harmful, that many would
want to be screened. In fact, JAMA Internal Medicine pub-
lished the results of an online survey of middle-aged Ameri-
cans, most of whom had been screened for either breast or pros-
tate cancer, which found that about half said they would not
have a screening test if it resulted in more than 1 overtreated
person per 1 cancer death averted.5 Yet, that is clearly the case
for mammography in women younger than 50 years. In a na-
tional survey, less than 50% of American women reported that
their physician discussed the pros and cons of mammography.6
In contrast, the British National Health Service informs women
that they may avoid death from breast cancer, but also tells
them that they have a 3-fold higher chance of overdiagnosis
than of avoiding a breast cancer death.7
More Important, What Can We Do About Overuse?
In JAMA Internal Medicine, we have seen many studies of vari-
ous educational interventions, feedback of performance met-
rics, and changes in electronic order sets to discourage over-
use. In general, these interventions have some positive impact
but the effect is small. We have, however, begun to see more
robust, multifaceted interventions based on implementation
science8 that do impact systems9 and physician10 behavior. We
have also seen that informed shared decision making and use
of decision aids can change patient behavior. Perhaps the most
effective way to discourage overuse is an evidence-based pay-
ment system. For example, while the Affordable Care Act man-
dates coverage of cancer screening where the USPSTF finds
Grade A or B evidence for screening (high certainty that the
(Reprinted) JAMA Internal Medicine Published online April 10, 2017 E1
 Opinion Editorial

net benefit is substantial or moderate), it is silent on coverage
of screening with Grade D evidence (moderate or high cer-
tainty that the service has no net benefit or that the harms out-
weigh the benefits). Limiting coverage of tests known to be
harmful is a win-win for patients and the national health care
system. Limiting coverage would reduce the harms of such
tests, including radiation exposure, adverse effects, overdi-
agnosis, and the risks and anxiety associated with inevitable
downstream additional testing, biopsies, and procedures re-
lated to false-positive test results. Limiting coverage for harm-
ful tests would also save money for patients, the health care
system, and ultimately the taxpayer. Patients bear the cost of
out-of-pocket charges for procedures and of rapidly rising in-
surance premiums. At least 30% of US health care dollars are
spent on overuse of tests and procedures.11 About 5 years ago,
one of us (R.F.R.) estimated that Medicare wastes $75 to $150
billion annually on overuse.12 The billions of dollars wasted has
only increased by 2017, along with countless persons harmed
and lives shortened by unnecessary medical testing and pro-
cedures. Certainly, truly informed decision-making would help
decrease unnecessary testing. However, we need to reduce the
many factors driving the continued use of tests of question-
able value or known to be harmful. Ultimately, alternative pay-
ment systems that value evidence-based, patient-centered out-
comes would improve patient care, choice, and satisfaction
while decreasing wasteful spending.

ARTICLE INFORMATION /Document/UpdateSummaryFinal/breast-cancer //www.nhs.uk/Conditions/breast-cancer-screening

Author Affiliations: University of California,
San Francisco, San Francisco (Grady, Redberg);
San Francisco VA Medical Center, San Francisco,
California (Grady); Editor, JAMA Internal Medicine
(Redberg).
Corresponding Author: Deborah Grady, MD, MPH,
San Francisco VA Medical Center, 550 16th St,
PO Box 0558, San Francisco, CA 94158
(deborah.grady@ucsf.edu).
Published Online: April 10, 2017.
doi:10.1001/jamainternmed.2017.0458
Conflict of Interest Disclosures: None reported.
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