Canadian Radiologists Do Not Support Screening Mammography Guidelines of the Canadian Task Force on Preventive Health Care

Canadian Radiologists Do Not Support Screening Mammography Guidelines of the Canadian Task Force on Preventive Health Care

Canadian Association of Radiologists Journal xx (2017) 1e10 www.carjonline.org Health Policy and Practice / Sante: politique et pratique medicale ...

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Canadian Association of Radiologists Journal xx (2017) 1e10 www.carjonline.org

Health Policy and Practice / Sante: politique et pratique medicale

Canadian Radiologists Do Not Support Screening Mammography Guidelines of the Canadian Task Force on Preventive Health Care Jean M. Seely, MD, FRCPCa,*, Jiyon Lee, MDb, Gary J. Whitman, MD, FSBIc, Paula B. Gordon, OBC, MD, FRCPC, FSBId a

Department of Medical Imaging, Breast Imaging Section, the Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada b Breast Imaging Section, Department of Radiology, NYU School of Medicine, New York, New York, USA c Breast Imaging Section, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA d Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada; Sadie Diamond Breast Program, BC Women’s Hospital and Health Centre, Vancouver, British Columbia, Canada

Abstract Purpose: The study sought to determine screening mammography recommendations that radiologists in Canada promote to average-risk patients and family or friends, and do or would do for themselves. Methods: An online survey was delivered from February 19, 2014, to July 11, 2014. Data included radiologists’ recommendations for mammography and their personal screening habits based on gender. The 3 radiologists’ cohorts were women 40 years of age, women <40 years of age, and men. The distribution of responses for each question was summarized, and proportions for the entire group and individual cohorts were computed. Results: Of 402 surveys collected, 97% (299 of 309) radiologists recommended screening every 1-2 years, 62% (192 of 309) starting 40 years of age and 2% (5 of 309) recommended screening every 2-3 years for women 50-74 years of age. Recommendations were similar for family and friends: 96% (294 of 305) recommended screening every 1-2 years, 66% (202 of 305) recommended screening every 1-2 years for women 40 years of age, and 2% (5 of 305) recommended screening every 2-3 years. For women radiologists 40 years of age, 76% (48 of 63) underwent screening every 1-2 years and started at 40 years of age, 76% (16 of 21) female radiologists <40 years of age would undergo screening 40 years of age, 100% every 1-2 years, and 90% (151 of 167) male radiologists would undergo screening every 1-2 years, with 71% (120 of 169) beginning at 40 years of age. Conclusion: The majority of Canadian radiologists recommend screening mammography every 1-2 years for average-risk women 40 years of age, whether they are patients or family and friends. Resume Objet : L’etude visait a determiner les recommandations en matiere de mammographies de depistage que les radiologistes canadiens font aux patients a risque moyen, aux membres de leur famille et a leurs amis, ainsi que les habitudes qu’ils adoptent ou adopteraient pour eux-m^emes. Methodes : Un questionnaire en ligne a ete envoye du 19 fevrier au 11 juillet 2014. Il portait notamment sur les recommandations des radiologistes en matiere de mammographies et leurs propres habitudes de depistage, selon leur sexe. Les trois cohortes de radiologistes etaient formees de femmes de 40 ans et plus, de femmes de moins de 40 ans et d’hommes. La repartition des reponses a chaque question a ete resumee, et les proportions ont ete calculees pour l’ensemble du groupe ainsi que pour chaque cohorte individuellement. Resultats : Parmi les 402 questionnaires remplis, 97 % (299 sur 309) des radiologistes recommandent un depistage tous les ans ou tous les deux ans, 62 % (192 sur 309) a partir de 40 ans, et 2 % (5 sur 309) recommandent un depistage tous les deux ou trois ans pour les femmes de 50 a 74 ans. Les recommandations sont similaires pour les membres de la famille et les amis: 96 % (294 sur 305) recommandent un depistage tous les ans ou tous les deux ans, 66 % (202 sur 305) recommandent un depistage tous les ans ou tous les deux ans pour les femmes de 40 ans, et 2 % (5 sur 305) recommandent un depistage tous les deux ou trois ans. Chez les femmes radiologistes de 40 ans et plus, 76 % (48 sur 63) subissent un examen de Disclosures: Dr Whitman has a book contract with Cambridge University Press. Dr Gordon has served on the scientific advisory boards for Hologic and Real Imaging. * Address for correspondence: Jean M. Seely, MD, FRCPC, Department of Medical Imaging, Breast Imaging Section, the Ottawa Hospital,

University of Ottawa, 501 Smyth Rd, Ottawa, Ontario K1H 8L6, Canada. E-mail address: [email protected] (J. M. Seely).

0846-5371/$ - see front matter Ó 2016 Canadian Association of Radiologists. All rights reserved. http://dx.doi.org/10.1016/j.carj.2016.08.004

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J. M. Seely et al. / Canadian Association of Radiologists Journal xx (2017) 1e10

depistage tous les ans ou tous les deux ans depuis l’^age de 40 ans, 76 % (16 sur 21) des femmes radiologistes de moins de 40 ans feraient des examens de depistage a partir de 40 ans, dont 100 % d’entre elles tous les ans ou tous les deux ans, et 90 % (151 sur 167) des hommes radiologistes subiraient un examen de depistage tous les ans ou tous les deux ans, dont 71 % (120 sur 169) a partir de 40 ans. Conclusions : La majorite des radiologistes canadiens recommandent une mammographie de depistage tous les ans ou tous les deux ans aux femmes a risque moyen de 40 ans et plus, qu’elles soient des patientes, des membres de la famille ou des amies. Ó 2016 Canadian Association of Radiologists. All rights reserved. Key Words: Breast cancer; Mammography; Screening, Screening guidelines; Canadian Task Force on Preventive Health Care

In 2009, the U.S. Preventive Services Task force (USPSTF) announced major revisions to its breast cancer screening recommendations that significantly changed the 2002 guidelines for average-risk women [1]. The Canadian Task Force on Preventive Health Care (CTFPHC) published its own recommendations on screening for breast cancer for average-risk women 40-74 years of age in 2011, which had changed markedly since 2001 [2]. The Canadian recommendations were based on the systematic review from the USPSTF. The 2011 Canadian Task Force recommended against routine mammography for women 40-49 years of age, and recommended routine mammography every 23 years for women 50-74 years of age. Radiologists deal usually with the impact of screening mammography on patients’ lives. Radiologists are the first physicians to diagnose breast cancer, participating in screening and diagnostic examinations of patients as part of their daily work. Radiologists are often in a position to provide recommendations for breast screening with their patients, and to influence patients’ behaviors. Physicians’ recommendations can influence patients’ health behaviors, so this influence should be used with care [3e5]. Physicians’ credibility and the effectiveness of their recommendations may be increased if their own behaviors are consistent with those recommendations [6,7]. Radiologists are also patients, and radiologists must balance the same health care decisions as their patients. A recent study was undertaken to evaluate screening recommendations that breast radiologists in the United States promote to average-risk patients, to their average-risk family members and friends, and implement for themselves [8]. This study demonstrated that American radiologists did not follow the USPSTF guidelines. To date, there have been no studies evaluating the screening recommendations of Canadian radiologists. We undertook this study to evaluate Canadian radiologists’ screening recommendations and to determine if they are in line with CTFPHC guidelines and if they practice what they preach. Materials and Methods Research Ethics approval was deemed exempt by our institutional board. Study Participants Radiologists registered in their provincial radiology associations were approached with a voluntary anonymous online survey. Ten provincial radiology associations (British

Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland and Labrador) agreed to participate in the study. Recruitment was launched on February 19, 2014. A total of 2334 radiologists are currently registered for practice in Canada. The 2 largest provincial associations provided distribution numbers: 596 in Quebec and 671 in Ontario. A concerted effort was made to reach Canadian radiologists in every province and territory, and to sample widely across various radiology practices and geographic locations. The survey was translated into French, and the French survey was distributed to all Quebec radiologists. The English survey was distributed to the remaining 9 provinces. The survey was closed on July 11, 2014. Survey Tool and Questions Participants accessed the survey via a cloud-based Internet tool (Survey Monkey). The survey consisted mostly of multiple-choice questions, with some free text options. Each completed survey response represented a unique radiologist. The questions were grouped into 6 sections. In section 1, participants provided personal and professional background information. Radiologists were asked for their sex and their age, which, by using survey question logic, determined which series of questions they would then see regarding personal screening habits. Those radiologists who provided both gender and age were divided into 3 cohorts: women 40 years of age and older, women younger than 40 years of age, and all male radiologists. In section 2, participants were asked for details regarding their radiology practices. The responses pertaining to patients’ demographics were collected for qualitative analysis. For section 3 (recommendations given the average-risk patients) and section 4 (recommendations given to average-risk family members and friends). For section 5, group 1 (screening implemented for self, female radiologists 40 years of age or older), participants in this cohort were asked whether they had had mammography and if so, at what age was the first examination; if they had or would undergo routine mammography (choices: every 1-2 years, 12-16 months, or 2-3 years); and when they would discontinue screening. Those radiologists who had not had mammography were given a free text option to provide reasons why they had not had mammography. They were also asked about their clinical breast exam (CBE) and self breast exam (SBE) habits. Those radiologists who had had

Canadian radiologists’ perspectives regarding screening mammography / Canadian Association of Radiologists Journal xx (2017) 1e10

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Table 1 Radiologists’ (n ¼ 402) personal and professional background English Age (y) 21-29 2 30-39 53 40-49 77 50-59 76 60 and older 43 Total eligible 251 Age not provided 0 False starts and foreign 31 Total started 282 Race or ethnicity White 197 Asian or Asian American 39 Multiple races 2 Other race 9 Black or African American 2 Aboriginal 1 Total 250 Risk factors for breast cancer Yes 27 No 224 Total 251 Fellowship training Yes 42 No 204 Total 246 Years in practice, median Years median 15 Range 0-40 Total 246 Participate in regular breast CME Yes 227 No 20 Total 247 Personal yearly mammography case volume Number, median 2000 Range 0-12,000 Total 220 Breast imaging or total personal radiology case volume <20% 141 20-50% 66 51-85% 12 >85% 11 Total 230 Screening/diagnostic case volume 0% screening/100% diagnostic 18 20% screening/80% diagnostic 11 40% screening/60% diagnostic 12 60% screening/40% diagnostic 55 80% screening/20% diagnostic 95 100% screening/0% diagnostic 2 50% screening/50% diagnostic 30 Total 223 Which modalities interpreted Mammography 90 Ultrasound 89 MRI 36 Other 15 Total 230 Perform breast interventions? Yes 71 No 20 Total 91

%

French

%

Total

%

1 21 31 30 17 100

1 21 18 33 19 92 2 26 120

1 23 20 36 21 100

3 74 95 109 62 343 2 57 402

1 22 28 32 18 100

79 16 1 4 1 0

89 2 1 0 0 0 92

97 2 1 0 0 0

286 41 3 9 2 1 342

84 12 1 3 1 0

11 89 100

15 77 92

16 84 100

42 301 343

12 88 100

17 83 100

30 62 92

33 67 100

72 266 338

21 79 100

16 0-43 92 92 8 100

84 7 91

15 0-43 338 92 8 100

1500 0-10,000 84

311 27 338

92 8 100

1550 0-12,000 303

61 29 5 5 100

48 28 9 4 89

54 31 10 4 100

189 94 21 15 319

59 29 7 5 100

8 5 5 25 43 1 13 100

6 6 10 18 32 2 14 88

7 7 11 20 36 2 16 100

24 17 22 73 127 4 44 311

8 5 7 23 41 1 14 100

39 39 16 7 100

86 86 23 8 203

42 42 11 4 100

176 175 59 23 433

41 40 14 5 100

78 22 100

67 20 87

77 23 100

138 40 178

78 22 100 (continued)

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Table 1 (continued )

Which breast interventions? Stereotactic guided biopsies Ultrasound-guided biopsies MRI-guided biopsies Needle localizations Other Total at least 1 Geographic area Rural (<2500 people) Suburban (2500e25,000 people) Small city (25,000e50,000 people) Large city (>50,000 people) Other Total responses Practice type Academic Cancer centre Community teaching hospital Community nonteaching hospital Private outpatient centre Teleradiology Private solo practice Private group practice Tertiary care centre Community health centre

English

%

French

%

Total

%

134 170 47 167 18 172

78 99 27 97 10 100

49 64 11 59 8 65

75 98 17 91 12 100

183 234 58 226 26 237

77 99 24 95 11 100

2 18 29 198 1 248

1 7 12 80 0 100

0 10 17 63 3 93

0 11 18 68 3 100

2 28 46 261 4 341

1 8 13 77 1 100

58 50 76 80 51 21 5 86 30 6

12 11 16 17 11 4 1 18 6 1

24 20 26 32 7 14 9 36 9 2

13 11 14 17 4 7 5 19 5 1

82 70 102 112 58 35 14 122 39 8

12 11 16 17 9 5 2 19 6 1

CME ¼ continuing medical education; MRI ¼ magnetic resonance imaging.

mammography were asked if they had interpreted and dictated their own mammography reports. For section 5, screening implemented for self, female radiologists younger than 40 years of age, participants in this cohort were asked whether they had had mammography and if so, at what age was the first examination; if they had or would undergo routine mammography (every 12-16 months); and when they would discontinue screening. Those radiologists who had not had mammography could further clarify if the reason was that they were younger than 40 years of age and of average risk, or if there was another reason; they were also asked whether they anticipated undergoing routine mammography and if so, starting when and for how long. CBE and SBE habits were also queried. For section 5, screening for self, male radiologists, all ages, male participants were asked whether, if they were women, would they have routine mammography (at approximately 12- to 16-month intervals), and would they undergo CBE and perform SBE. For section 6 (questions for all radiologists, regarding personal health habits), participants were queried on 3 health habits: did they currently smoke, how much time per week did they engage in at least moderately vigorous exercise (choices were none, 1-60 minutes, 1-2 hours, 2-2.5 hours, or more than 2.5 hours), and how many days in the past 30 days they had had more than 1 alcoholic beverage. Statistical Analysis The results were summarized in frequency tables (for qualitative characteristics) and with summary statistics

(means and medians) as applicable. Any free text answers were summarized in descriptive qualitative fashion. Results There were 402 surveys collected from 10 Canadian provinces: 120 (30%) in French and 282 (70%) in English (see Table 1). A total of 57 (31 English and 26 French) surveys were excluded for false starts or lack of information beyond preliminary radiologists’ background information). At least 1 response came from all 10 provinces. These completed surveys comprise the study set. Percentages of responses and number of responses are reported. A total of 345 responses were collected. The results are summarized in Table 2, according to total responses and the 3 study cohorts. Not all radiologists answered every question and the numbers are based on responses to specific questions and the percentages are provided relative to the number of responses for each section. The 3 study cohorts reported were 89 (30%) female radiologists 40 years of age, 26 (9%) female radiologists <40 years of age, and 177 (61%) male radiologists, for a total of 292 responses. Recommendations for Patients In total, 97% (299 of 309) radiologists recommended screening every 1-2 years: 87 (28%) recommended screening annually for all women 40 years of age; 47 (15%) recommended screening biennially for women 40 years of age; 58 (19%) recommended annual screening for women 40-50 years of age, then biennial screening for women

Canadian radiologists’ perspectives regarding screening mammography / Canadian Association of Radiologists Journal xx (2017) 1e10

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Table 2 Radiologists’ recommendations for screening mammography, clinical breast exam, and self breast exam for patients, family, and friends and themselves

Patients

Total participantsa

Female radiologists 40 years old

Female radiologists <40 years old

Male radiologists

Total

Total

Total

Total

%

Screening mammography Yearly for those 40 years old 87 28 Biennial for 40 y 47 15 Annual 40-50 years old, then biennial 58 19 50-74þ years old Biennial for those 50e74 years old 107 35 Every 1-2 y 299 97 Total start screening 40 y 192 62 Every 2-3 y 5 1.6 Don’t do mammography or recommend 6 2 discussion with family physician Total 309 100 Clinical breast examination Yearly 190 64 Every 2-3 y 12 4 Other 93 32 Total 295 100 Self breast examination Monthly, according to menstrual cycle if 165 60 applicable Other 110 40 Total 275 100 Family members and friends Screening mammography Yearly for those 40 years old 106 35 Biennial for 40 y 44 14 Annual 40-50, then biennial 50-74þ 52 17 Total start screening 40 y 202 66 Biennial for those 50e74 years old 92 30 Every 2-3 y 5 1.6 Don’t do mammography or recommend 6 2 discussion with family physician Total 305 100 Clinical breast examination Yearly 190 64.4 Every 2-3 y 12 4.1 Other 93 31.5 Total 295 100 Self breast examination Monthly, according to menstrual cycle 165 60 if applicable Other 110 40 Total 275 100 Would do or do for themselves Age to start screening 40 y 189 72.7 50 y 49 18.8 45 y 21 8.1 Total 260 100 Screening interval 12-16 mo 82 32.7 1-2 y 138 55 2-3 y 31 12.4 Total 251 100 Do you or would you undergo routine clinical breast examination? Yes 208 74 No (please specify reason) 73 26 Total 281 100

%

21 16 17

23.6 18 19

8 5 5

33 87 54 1 1

37 98 60.6 1.1 1.1

7 25 18 1 0

% 31 19 19 27 96 69 3.9 0

%

54 26 34

30.5 14.7 19.2

56 170 114 2 5

31.6 96 64.4 1.1 2.8

89

100

26

100

177

100

52 4 29 85

61.2 4.7 34.1 100

12 1 12 25

48 4 48 100

119 3 48 170

70 1.8 28.2 100

47

59.5

11

47.8

100

62.5

32 79

40.5 100

12 23

52.2 100

60 160

37.5 100

27 12 13 52 31 3 3

30.3 13.5 14.6 58.4 34.8 3.4 3.4

10 5 4 19 6 1 0

38.5 19.2 15.4 73.1 23.1 3.8 0

62 25 34 121 52 1 3

35 14.1 19.2 68.3 29.4 0.6 1.7

89

100

26

100

177

100

52 4 29 85

61.2 4.7 34.1 100

12 12 1 25

48 48 4 100

119 3 48 170

70 1.8 2.8 100

47

59.5

11

47.8

100

62.5

32 79

40.5 100

12 23

52.2 100

60 160

37.5 100

53 5 12 70

75.7 7.1 17.1 100

16 5 0 21

76 24 0 100

120 39 9 169

71 23 5 100

21 27 15 63

33.3 42.9 23.8 100

19 2 0 21

90.5 9.5 0 100

42 109 16 167

25 65 10 100

55 33 88

62.5 37.5 100

15 9 24

62.5 37.5 100

138 31 169

82 18 100 (continued)

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J. M. Seely et al. / Canadian Association of Radiologists Journal xx (2017) 1e10

Table 2 (continued )

Patients

Total participantsa

Female radiologists 40 years old

Female radiologists <40 years old

Male radiologists

Total

Total

%

Total

%

Total

%

34 17 51

67 33 100

9 5 14

64.3 35.7 100

71 57 128

55 45 100

64 22 86

74 26 100

16 8 24

66.7 33.3 100

106 53 120

88 44 100

%

If you would do clinical breast examination, at what interval? Yearly 114 59.1 Other 79 40.9 Total 193 100 Would you do self-breast examination? Yes 186 80.9 No 83 36.1 Total 230 100 a

Not every radiologist who responded provided gender and age.

50-74 years of age; and 107 (35%) recommended biennial screening for women 50-74 years of age. Only 1.6% (5 of 309) of radiologists recommended screening every 2-3 years (Figure 1), and another 1.6% (5 of 309) radiologists did not do mammography or recommended discussion with their family physician. For the age at which to start screening, 62% (192 of 309) radiologists recommended beginning screening at 40 years of age, and 35% (107 of 309) recommended starting at 50 years of age (Figure 2). The 3 study cohorts were similar in their recommendations, with 98%, 96%, and 96% of each group recommending screening every 1-2 years, and 61%, 69%, and 64% recommending starting screening 40 years of age. Regarding CBE with 295 responses, 64% (190 of 295) recommended yearly CBE and 4% (12 of 295) recommended

CBE every 2-3 years, and 12% (35 of 295) made no recommendations. There were 275 responses regarding SBE and 60% (165 of 275) recommended monthly SBE. Another 5 radiologists (1.8%) suggested a version of SBE or breast awareness to patients. Recommendations to Average-Risk Family Members and Friends Regarding screening mammography, 96% (294 of 305) of radiologists recommended screening every 1-2 years: 35% (106 of 305) recommended annual screening for women 40 years of age; 14% (44 of 305) recommended biennial screening for women 40 years of age; 17% (52 of 305) recommended annual screening for women 40-50 years of

Figure 1. Bar graph depicting the Canadian Task Force on Preventive Health Care (CTFPHC) and the radiologists’ recommendations for screening intervals for patients, family, and friends and for themselves.

Canadian radiologists’ perspectives regarding screening mammography / Canadian Association of Radiologists Journal xx (2017) 1e10

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Figure 2. Bar graph depicting the Canadian Task Force on Preventive Health Care (CTFPHC) and the radiologists’ recommendations for age to begin screening for patients, family, and friends and for themselves.

age, then biennial screening for women 50-74 years; and 30% (92 of 305) recommend biennial screening for women 50-74 years of age. Only 1.6% (5 of 305) recommended screening every 2-3 years and 2% (6 of 305) did not do mammography or recommended discussion with their family physician. A total of 66% (202 of 305) of radiologists recommended screening mammography beginning at 40 years of age, and 30% (92 of 305) recommended starting at 50 years of age. The groups were similar, with 97%, 96%, and 99% of each group recommending screening every 1-2 years. For CBE, 70% (193 of 305) recommend annual CBE, 4% recommended CBE every 2-3 years, and 7.9% (24 of 305) made no recommendations. For SBE, 65% (169 of 261) recommended monthly SBE, and 4% (11 of 261) recommended breast awareness or occasional SBE. Recommendations for Self Regarding screening mammography, 88% of radiologists would screen every 1-2 years (33% every 12-16 months, and 55% every 1-2 years), and 12% would screen every 2-3 years. A total of 73% of radiologists began or would begin screening at 40 years of age, 8% at 45 years of age, and 19% at 50 years of age. This was consistent with their recommendations for patients, family, and friends. This was consistent across the 3 groups of radiologists, with 76% of female radiologists 40 years of age, 76% of those

<40 years of age, and 71% of male radiologists starting screening for themselves at 40 years of age. Regarding screening interval, there were differences between the groups, and 24% of female radiologists 40 years of age, none of the female radiologists <40 years of age, and 10% of male radiologists would screen every 2-3 years. Six radiologists 40 years of age stated they would do mammography more often but ran out of time. Of the remaining female radiologists 40 years of age, 43% (27 of 63) would screen every 1-2 years and 33% (21 of 63) every 12-16 months. A total of 86% of female radiologists 40 years of age (62 of 72) and 76% (13 of 17) of those <40 years of age planned to continue with regular screening mammography for as long as they were in good health, and the others would stop between 70-100 years of age or a life expectancy of <5 years. Regarding CBE, 62% (53 of 86) of the female radiologists 40 years of age underwent routine CBE, and the others did not undergo routine CBE for the following reasons: 9 (10.5%) did it themselves, 3 (3.5%) had physicians who do not offer it, 1 had a bilateral mastectomy, 11 (12.8%) did not have a family physician or were delayed in getting to see a physician, and 1 had a male physician. Sixty-seven percent (34 of 51) underwent annual CBE, 11.8% (6 of 51) every 2 years and 4% (2 of 51) every 6 or 18 months. Regarding SBE, 74% (64 of 86) did it, 7% (6 of 86) did not do SBE because they forgot to do it, and 10.5% (9 of 86) did not do

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J. M. Seely et al. / Canadian Association of Radiologists Journal xx (2017) 1e10 Start age (y)

Interval Current guidelines under review

Begin at 50 (40-49 years of age accepted by physician referral for initial screen but not actively recruited) Begin at 50 (40-49 years of age accepted by self-referral but not actively recruited)

For women 40-49 years of age—annual recall

Nunavut Northwest Territories Yukon

For women 50-74 years of age—biennial recall For women 50-69 years of age—biennial recall For women 70-74 years of age—biennial recall For women 40-49 years of age—biennial recall

British Columbia

Begin at 50 (40-49 years of age accepted by self-referral but not actively recruited)

Alberta

Begin at 50 (40-49 years of age accepted with physician referral for the first screen)

Saskatchewan

Begin at 50 (49 years of age accepted on the mobile if turning 50 in same calendar year)

Manitoba

Begin at 50 (40-49 years of age accepted to mobile unit only with physician referral)

Ontario

Begin at 50 (30-49 years of age accepted if high risk and referred by physician)

For women 50-69 years of age—biennial recall For women 70-74 years of age—biennial recall For higher-than-average-risk women 40-74— annual recall For women 40-49 years of age—annual recall For women 50-69 years of age—biennial recall

Stop age (y)

75 74 (age 75+ accepted by self-referral, but not recalled) 74 (75+ accepted by self-referral but not actively recruited or recalled) 75+a (since September 2013)

For women 50-74 years of age—biennial recall For women 70-74 years of age—biennial recall (only if previously enrolled in the program)

75+

For women 40-49 years of age—biennial recall

74 (75+ accepted by self-referral but not actively recruited or recalled)

For women 50-69 years of age—biennial recall For women 70-74 years of age—biennial recall For high-risk women 30-49 years of age— annual recall

75+

For high-risk women 50-69 years of age— annual recall

74 (75+ only with a primary care provider referral)

For women 50-69 years of age—biennial recalla For women 70-74 years of age—biennial recalla

Québec

Begin at 50 (accept 35-49 years of age only with physician referral if done at a program designated screening or referral centre)

For women 50-69 years of age—biennial recall

New Brunswick

Begin at 50 (40-49 years of age accepted only with physician or nurse practitioner referral)

For women 50-74 years of age—biennial recall

Nova Scotia

Begin at 50 (40-49 years of age accepted by self-referral but not actively recruited)

Prince Edward Island

Begin at 40 years of age

Newfoundland & Labrador

For women 40-49 years of age—annual recall For women 50-69 years of age—biennial recall

69 (70+ only with a physician referral at a program designated screening or referral centre) 74 (74+ only with a physician or nurse practitioner referral; since June 1, 2013) 70+

For women 40-49 years of age—annual recall For women 50-69 years of age—biennial recall

74

For women 70-74 years of age—biennial recall Begin at 50 years of age

For women 50-74 years of age—biennial recall

74 (74+ only if previously enrolled in the program)

Figure 3. Breast cancer screening programs: provincial and territorial guidelines for asymptomatic women at average risk. aWomen who meet specific criteria that may put them at increased risk for breast cancer will be recalled annually. Highlighted boxes indicate provinces where screening programs include women 40-49 years of age (Adapted from Cancerview.ca) [18].

SBE because they did not believe that it was useful or because they had lumpy breasts. Discussion In this study of Canadian radiologists, only 2% agreed with CTFPHC guidelines for screening intervals for patients, family, and friends. More than 62% recommended screening every 1-2 years beginning at 40 years of age, and

this was consistent with what they did or would do for themselves. Many radiologists’ recommendations were in accordance with their provincial screening program recommendations (see Figure 3), which vary across each province. The majority of radiologists in this study recommended starting screening at 40 years of age. Not all Canadian provincial screening programs are the same: some provinces accept women 40-49 years of age with a physician referral

Canadian radiologists’ perspectives regarding screening mammography / Canadian Association of Radiologists Journal xx (2017) 1e10

(Northwest Territories, Alberta, Saskatchewan, Manitoba, Quebec, New Brunswick, Newfoundland and Labrador) or are a part of the provincial screening program (British Columbia, Yukon, Nova Scotia, Prince Edward Island). In Ontario, women under 50 years of age may be screened outside of the provincial screening program at a diagnostic centre. Screening that is not according to the guidelines of the CTFPHC is common [9]. A significant amount of screening occurs outside of the recommended age groups and intervals of the CTFPHC guidelines. In 2009-2012, the self-reported rate of screening at 24 months among women 40-49 years of age was 29%, as compared with 62% for 50-69-year-olds, and in women 75 years of age and older it was 24% [9]. This study is based on Canadian radiologists’ practices, and the results counteract the notion that a lack of adherence to CTFPHC guidelines is due to ‘‘opinion.’’ The data show that there is widespread support for adopting other screening strategies than the CTFPHC guidelines. Potential reasons for lack of adherence to any guideline include lack of awareness, lack of familiarity, lack of agreement, and lack of outcome expectancy [10]. In a study of physician surveys, 10% of respondents disagreed with a guideline due to differences in interpretation of the evidence [10]. With respect to our study, Canadian radiologists are not complying with the CTFPHC guidelines due predominantly to lack of support for the guidelines. If a physician believes that a recommendation will not lead to an improved outcome, the physician will be less likely to adhere to that recommendation [10]. Most radiologists believe that screening mammography leads to reduced breast cancer mortality, and radiologists are unlikely to recommend different screening practices if they feel that the altered screening practices will lead to a reduced benefit. Radiologists work firsthand with the results of screening mammography. Radiologists perform diagnostic workups on women who have been recalled from screening and are aware of the fact that most false positives are not of concern. They reassure women at the time of their workup evaluations to minimize anxiety associated with mammography. Most radiologists believe that the so-called false positives are not deterrents to undergoing screening mammography, as seen by the results of this survey. Other studies have shown similar findings. A recent survey of breast surgeons in the United States demonstrated that 85% (197 of 232) recommend annual screening mammograms starting at 40 years of age for patients and 86% (200 of 232) for their patients and family and friends [11]. The 2009 USPSTF guideline of biennial screening mammography between 50-74 years of age was advocated by 6% (14 of 232) and 7% (17 of 232) of surgeons for their patients and family and friends, respectively. Regarding personal screening habits, 88% (80 of 91) of female radiologists 40 years of age and older did and 97% (29 of 30) of those younger than 40 years of age did or would undergo annual mammography. Most male radiologists 94% (98 of 104) would undergo annual mammography [11]. A survey based

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on the same questions was asked of breast radiologists in the United States [8]. Of 487 surveys collected, none of the radiologists’ recommended biennial mammography for patients 50-74 years of age, with 98% (477 of 487) recommending yearly mammography for patients 40 years of age and older and 98.7% (470 of 476) recommending yearly mammography for family and friends 40 years of age and older. The U.S. study included a significant percentage of breast imaging subspecialists, which may in part explain differences from our results. Another study evaluating physicians’ attitudes and behaviors towards screening mammography in women 40-49 years of age showed that 46% of family physicians routinely offered screening mammography to women 40-49 years of age who were at average risk for breast cancer [12]. In conjunction with these studies, our study demonstrates a widespread lack of adherence to CTFPHC or USPSTF guidelines. The guidelines have not been developed by a knowledgeable, multidisciplinary panel of experts and representatives from key affected groups, as recommended in the National Academies of Medicine [13]. There is an under-recognized potential harm of omitting screening mammography. A recent study by Onitilo et al [14] showed that in the 1 year before breast cancer diagnosis, undergoing mammography decreased the risk of diagnosis with late-stage cancer by more than 12% in all women. The number of mammograms in the 5-year period before breast cancer diagnosis was inversely related to cancer stage [14]. These findings were true whether women were older or younger than 50 years of age, contrary to USPSTF guidelines. Radiologists also perform diagnostic mammography, ultrasound, and biopsy on women who present because of a palpable breast lump, in the absence of screening. They are therefore personally familiar with the difference in stage of disease at diagnosis between screendetected and clinically detected breast cancer. A failure analysis of breast cancers diagnosed at 2 Harvard-associated hospitals over a 10-year period showed that among 609 confirmed breast cancer deaths, 29% were among women who had been screened (19% screen-detected and 10% interval cancers), whereas 71% were among unscreened women [15]. Screening mammography shows the greatest benefit of a 39.6% mortality reduction through annual screening of women 40-84 years of age [16]. This screening regimen saves 71% more lives than the USPSTFrecommended regimen of biennial screening of women 50-74 years of age, which had a 23.2% mortality reduction [16]. A recent study reporting on data from 7 Canadian breast screening programs by Coldman et al [17] showed that in women who were actually screened, there was a 40% reduction in breast cancer mortality as compared with women who were not screened, regardless of age of entry into screening. There are limitations to this study. The data collection was done on an anonymous basis, which encouraged candid answers. However, the self-reported information cannot be independently verified. There may also be some selection

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J. M. Seely et al. / Canadian Association of Radiologists Journal xx (2017) 1e10

bias given the voluntary nature of the survey, with the possibility that radiologists who support screening were more likely to respond. As many radiologists in Canada include breast imaging in their scope of practice, recruitment was chosen to reach as many radiologists as possible, and not just those who were subspecialized breast imagers. A concerted effort was made to achieve a broad sampling of radiologists from very diverse geographic locations and practice venues. Conclusions The majority of Canadian radiologists recommend screening mammography every 1-2 years for average risk women 40 years of age, whether they are patients or family and friends. Most radiologists are consistent in what they do or anticipate that they would practice what they preach. Acknowledgements These data reflect what Canadian radiologists consider to be optimal protocols for breast cancer screening. Their opinions may explain in part the number of women who are screened outside of the CTFPHC recommended age group in Canada. References [1] U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009;151:716e26. W-236. [2] Canadian Task Force on Preventive Health Care, Tonelli M, Connor Gorber S, et al. Recommendations on screening for breast cancer in average-risk women aged 40-74 years. CMAJ 2011;183: 1991e2001. [3] Villani J, Mortensen K. Patient-provider communication and timely receipt of preventive services. Prev Med 2013;57:658e63. [4] Gurmankin AD, Baron J, Hershey JC, Ubel PA. The role of physicians’ recommendations in medical treatment decisions. Med Decis Making 2002;22:262e71. [5] Ubel PA. Is information always a good thing? Helping patients make ‘‘good’’ decisions. Med Care 2002;40(9 Suppl):V39e44.

[6] Frank E, Breyan J, Elon L. Physician disclosure of healthy personal behaviors improves credibility and ability to motivate. Arch Fam Med 2000;9:287e90. [7] Oberg EB, Frank E. Physicians’ health practices strongly influence patient health practices. J R Coll Physicians Edinb 2009;39:290e1. [8] Lee J, Gordon PB, Whitman GJ. ‘‘Do unto others as you would have them do unto you’’: breast imagers’ perspectives regarding screening mammography for others and for themselvesedo they practice what they preach? AJR Am J Roentgenol 2015;204:1336e44. [9] Cancer screening in Canada: An overview of screening participation for breast, cervical and colorectal cancer. Toronto: Canadian Partnership Against Cancer; 2015. Available at: http://www.cancerview.ca/idc/ groups/public/documents/webcontent/joint_cancer_screening_en.pdf. Accessed February 28, 2016. [10] Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458e65. [11] Loving V, Tanaka E, Lee J. Mammography recommendations and personal screening habits of breast surgeons in the United States amid the screening mammography controversy since the 2009 USPSTF guidelines. Paper presented at: American Roentgen Ray Society Annual Meeting. April 19e24, 2015; Toronto, Ontario, Canada. [12] Smith P, Hum S, Kakzanov V, Del Giudice ME, Heisey R. Physicians’ attitudes and behaviour toward screening mammography in women 40 to 49 years of age. Can Fam Physician 2012;58:e508e13. [13] Institute of Medicine of the National Academies. Clinical practice guidelines we can trust. 2011. Available at: http://iom.national academies.org/w/media/Files/Report Files/2011/Clinical-Practice-Guidelines-We-Can-Trust/Clinical Practice Guidelines 2011 Insert.pdf. Accessed September 5, 2015. [14] Onitilo AA, Engel JM, Liang H, et al. Mammography utilization: patient characteristics and breast cancer stage at diagnosis. AJR Am J Roentgenol 2013;201:1057e63. [15] Webb ML, Cady B, Michaelson JS, et al. A failure analysis of invasive breast cancer. Cancer 2014;120:2839e46. [16] Hendrick RE, Helvie MA. United States Preventive Services Task Force screening mammography recommendations: science ignored. AJR Am J Roentgenol 2011;196:W112e6. [17] Coldman A, Phillips N, Wilson C, et al. Pan-Canadian study of mammography screening and mortality from breast cancer. J Natl Cancer Inst 2014;106:1e7. [18] Cancerview.ca. Breast cancer screening guidelines across Canada: environmental scan. Toronto, Canada: Canadian Partnership Against Cancer. Available at: http://www.cancerview.ca/cv/portal/Home/ PreventionAndScreening/PSProfessionals/PSScreeningAndEarlyDiagnosis/ BreastCancerScreening?_afrLoop¼30593688610000&lang¼en&_afr WindowMode¼0&_adf.ctrl-state¼csge1jwm_86. Accessed March 4, 2017.