Introduction/background

In the United States, breast cancer continues to be the second most common cancer diagnosis in female subjects, and the second leading cause of cancer death in women (American Cancer Society [ACS], 2020; Centers for Disease Control and Prevention [CDC], 2019). It is estimated that in 2020, 276,480 new diagnoses of breast cancer will occur, and 10% of those new cases will be found in women younger than 45 years (ACS, 2020; CDC, 2019; Surveillance, Epidemiology, and End Results Program [SEER], n.d.). Of women younger than 45 years, breast cancer is most commonly found in the African American race who also experience the overall highest death rate associated with breast cancer in comparison to White, Asian, Pacific Islander, Native American, Hispanic, and non-Hispanic women (Breastcancer.org, 2019; SEER, n.d.). Women with a first-degree relative (mother, sister, daughter) with a history of breast cancer have a near two-fold increased risk of developing breast cancer (Breastcancer.org, 2019). The lifetime breast cancer risk for women who have a BRCA1 or BRCA2 gene mutation is 72% and 69%, respectively, and is more prevalent in the younger population (Breastcancer.org, 2019). One in eight women will develop breast cancer in their lifetime, 15% will have an associated first-degree relative, and 5%-10% will be related to a genetic mutation (ACS, 2020; Breastcancer.org, 2019).

Review of the current guidelines

The recommendations for initiating breast cancer screening (BCS) with a mammogram, the frequency with which to continue monitoring, and the screening discontinuation age differ among reputable organizations and professional societies (Table 1).

Table 1. Breast cancer screening guidelines

Currently, the United States Preventive Services Task Force (USPSTF) recommends biennial mammograms for women starting at age 50 years and continuing until age 74 years (Siu, 2016). For women between 40 and 49 years, the USPSTF recommends selective screening based on individual factors, given a lower net benefit of avoided breast cancer deaths versus harm (Nelson et al., 2016a; Sui, 2016). In this case, harm is defined as overdiagnosis and overtreatment. However, it is difficult to quantify if evaluation and treatment of the diagnosed breast cancer found on imaging would "become a threat to a woman's health, or even apparent, during her lifetime" (Siu, 2016, p.280, para 2). The USPSTF proposed these guidelines using a meta-analysis highlighting absolute rates that out of every 10,000 women aged 40-49 years screened, there would be three fewer breast cancer deaths, in comparison to eight fewer deaths in women aged 50-59 years, and 21 fewer deaths in women aged 60-69 years who had routine screening (Nelson et al., 2016a). These data imply that younger women completing routine mammograms experience less breast cancer-related deaths than older women, which would be expected because the incidence averages of breast cancer diagnosis and death in the United States are between 62 and 68 years (SEER, n.d.). The USPSTF's analysis of BCS effectiveness regards breast cancer mortality reduction as the primary positive outcome across all ages, as all-cause mortality was not found statistically significant, and the incidence of advanced breast cancer diagnosis based on screening was only found reduced in women aged 50 years or older but not in women between 39-49 years (Nelson et al., 2016a).

The USPSTF categorizes women who are considered average risk as those without personal or familial breast cancer history, without known BRCA1 or BRCA2 gene mutation, and without a history of radiation therapy to the chest at a young age (Sui, 2016). The USPSTF recognizes women with familial breast cancer history or possible genetic BRCA1 or BRCA2 mutations at higher risk of developing breast cancer and may benefit from initiating screening earlier than 50 years (Nelson et al., 2016a; Sui, 2016). The USPSTF has a "B" recommendation for screening women for BRCA mutations, and referral for genetic counseling should occur starting at the age of 18 years and reassessed "periodically" (Moyer, 2014, p. 274, para 2). However, no further recommendations addressing the frequency of BRCA mutation screening is offered. Screening recommendations for potentially high-risk women include those with familial members with "breast, ovarian, tubal, or peritoneal cancer," in addition to a positive screening result from one screening risk model (Seven-Question Family History Screening Tool, Manchester Scoring System, Ontario Family History Assessment, Pedigree Assessment Tool, Referral Screening Tool) (Moyer, 2014, p. 271, para 4). Women with risk factors or whom may experience significant familial medical history changes over time may miss opportunities of being identified for early detection screening without concrete recommendations.

In contrast, the National Comprehensive Cancer Network (NCCN) and American College of Radiology (ACR) recommend annual mammogram screening starting at 40 years with discontinuation dependent on limited life expectancy (from factors such as comorbidities, age) determined by provider discretion and if no further interventions (i.e., additional imaging, biopsies, breast cancer treatment) were to be pursued regardless of mammogram imaging results (Bevers et al., 2018; Lee et al., 2010; Monticciolo et al., 2017). The NCCN and ACR advocate for annual screening starting at 40 years because this age group has the largest potential to experience the benefits of breast cancer mortality reduction, improved survival rates, and better breast cancer treatment options (Bevers et al., 2018; Lee et al., 2010). Per the ACS (2017), estimated breast cancer death rates in women between 40 and 49 years were 9%, 19% in women between 50 and 59 years, 23% in women between 60 and 69 years, 20% in women between 70 and 79 years, and the highest occurrence of 27% in women aged 80 years and above. The ACS's recommendation to start mammograms at 45 years is based on quality evidence ratings found in their conducted systematic review evaluating the harms and benefits of BCS in 5-year intervals (Oeffinger et al., 2015). American Cancer Society advocates for introducing the discussion for BCS at 40 years to identify women at a higher risk who would benefit from mammography earlier than 45 years (Oeffinger et al., 2015).

American College of Obstetricians and Gynecologists (ACOG, 2017) advises that women should be counseled on BCS and be offered the choice to start mammograms at 40 years (but no later than 50 years), which is determined through a shared decision between the patient and provider. American Cancer Society recommends annual screening mammogram to be started at 45 years until 54 years (with individually tailored screening between 40 and 44 years), then every 1-2 years starting at 55 years onward, until life expectancy is less than 10 years (Oeffinger et al., 2015). ACOG (2017) endorses counseling for BCS starting at 40 years, with the option to start mammography because evidence from the ACS and USPSTF reviews found that women receiving mammograms between 40 and 49 years experience quantifiable breast cancer mortality reduction (Nelson et al., 2016a; Oeffinger et al., 2015). ACOG (2017) also supports a patient's decision to defer beginning mammograms until 50 years because determining an appropriate balance between harm versus benefit is subjective and should incorporate the patient's priorities and beliefs. Overall, these guidelines propose patient involvement through a shared-decision making approach, suggesting that BCS may not fit a standardized "one size fits all" approach.

There is general consensus among ACOG, ACR, ACS, and NCCN that women with average risk of developing breast cancer are those without personal or familial breast/ovarian cancer history, genetic predisposition for suspected or known gene mutations, or have a history of ionizing radiation exposure to the chest at a young age (10-30 years) (ACOG, 2017; ACS, 2017; Bevers et al., 2018; Daly et al., 2017; Lee et al., 2010). Depending on the risk factor, women may benefit from earlier screening mammograms, additional imaging modalities, and genetic counseling. Identifying and following women who may not have initial risk factors but develop them over time should be a part of a routine assessment and reevaluated regularly for best the management of comprehensive BCS practices. Other breast cancer risk factors identified among these organizations include dense breast tissue, history of Ductal carcinoma in situ or Lobular carcinoma in situ, benign breast disorders, women of Ashkenazi Jewish decent, nulliparity or first pregnancy after 35 years, early menarche (age 11 or younger), late menopause (after 55 years), never having breastfed, postmenopausal combination hormone therapy, and postmenopausal high bone mineral density (ACOG, 2017; ACS, 2017; Lee et al., 2010). Environmental and behavioral influences contributing to breast cancer include alcohol consumption, tobacco smoking, obesity, diethylstilbestrol exposure, and working night shifts (ACOG, 2017; ACS, 2017).

The lack of uniform BCS guidelines or a standardized decision toolkit for when to implement screening has caused inconsistent practices in primary care, potentially affecting outcomes for all women, including those at an average or high risk. This difference in clinical practice ultimately impacts the opportunity to optimally screen and rescreen women for breast cancer in early detection, secondary, or tertiary care.

Search process

Given all the various guidelines, there remains confusion among providers, about which guideline is best and when to actually start screening. There is considerable debate about the risks of mammography screening causing "harm" to women in their 40s that could lead to increased false-positives requiring additional imaging, the risk of radiation-induced breast cancer from the cumulation of mammography, the potential for overdiagnosis, and additional psychological stress (Nelson et al., 2016b). The questions asked to further understand the current evidence, gaps, and risks of age-based routine BCS aimed to evaluate the guidelines for starting BCS by age, the outcomes of breast cancer identification in women aged 40-49 years, and the advantages versus disadvantages of screening early or late in women aged 40-49 years.

A systematic literature search was conducted in October 2018 and again in March 2019 to effectively evaluate available evidence. The databases searched were CINAHL, Cochrane Database of Systematic Reviews, and PubMed. Keywords and MESH terms included mammography, age factors, adverse effects, benefits, risk factors, BRCA1/2 mutations, family history, chest radiation outcomes, breast neoplasms, breast cancer, and screening alone and in combinations. Gray area literature and search engines used were ACOG, ACR, ACS, CDC, NCCN, UpToDate, and USPSTF. Reference lists of preliminary research articles were scanned for secondary articles that could be considered for further review. Inclusion criteria were articles published between 2008 and 2019 for the most current data and existing practices recommended to the public and health care providers (HCPs) regarding BCS and articles written only in the English language. A total of 136 articles were found; 21 were selected for further consideration based on the inclusion criteria, and 8 were included in this final review. Articles that did not further clarify and answer the reviews aim in evaluating best practice management of BCS in women aged 40-49 years were excluded. Multiple studies that were reviewed included meta-analysis, systematic reviews, prospective/retrospective studies, and practice guideline recommendations. The evidence was evaluated using the John Hopkins Research and Non-Research Evidence Appraisal Tools (2012a, 2012b) and rated for quality (Appendix A, Supplemental Digital Content 1, http://links.lww.com/JAANP/A51). The articles presented in this article range from Level I A to III C.

Review of literature

After thorough examination of the current evidence, the leading arguments of the potential risks and benefits of BCS practices are described to help educate the author and readers to make informed, comprehensive decisions about breast health. The themes of possible disadvantages toward screening women aged 40-49 years are false-positive recalls from mammography, false-positive readings leading to biopsy, overdiagnosis of breast cancer leading to potential unnecessary treatment, psychological stress, and mammography-related radiation risk. Beneficial themes of screening women aged 40-49 years reviewed are earlier stage of breast cancer diagnosis, decreased breast cancer-related mortality, increased number of lives saved from routine BCS, and the potential of years of life gained from earlier detection.

Disadvantages to breast cancer screening with mammography (for Women aged 40-49 Years)

False-positives

The potential risk for women receiving a false-positive finding from a mammogram that is truly negative for breast cancer has been documented as a considerable factor that can influence the individual decisions toward BCS. Pace and Keating (2014), the USPSTF, and the ACS systematic reviews demonstrate a 61.3% (95% confidence interval [CI]) risk of receiving at least one false-positive finding over 10 years in women who started annual screening at 40 years, and 41.6% (95% CI) for those continuing with biennial screening (Nelson et al., 2016b; Oeffinger et al., 2015). However, comparable estimates for false-positives in women starting mammogram screening in their 50s were discovered at 61.3% (95% CI) annually and 42% biennially (Nelson et al., 2016b; Oeffinger et al., 2015; Pace & Keating, 2014). This evidence confirms that women in their 40s will experience near-identical estimates of false-positive recalls compared with those in their 50s regardless of the screening interval. The systematic review of van den Ende et al. (2017) examined the effects of BCS for only women aged 40-49 years and found a 20.5% cumulative risk of experiencing a false-positive finding within the first seven mammograms. This evidence suggests that lower false-positive findings are possible in women aged 40-49 years than what is reported by the USPSTF, ACS, and Pace and Keating (2014) systematic reviews. The decision to choose whether this disadvantage outweighs to begin mammogram screening during 40 or 50 years should be the choice of the individual undergoing the intervention rather than the standardized guidelines produced by governing institutions.

Myers et al. (2015) found that false-positive mammograms leading to biopsy recommendations for a first time screen increased with age (odds ratio [OR], 1.40 for 40-44 years; OR, 1.75 for 50-54 years; OR, 1.75 for 55-59 years). Over the course of 10 years, cumulative estimates of biopsy recommendation from false-positive mammograms exhibit a 7% (95% CI) increased risk during annual screening among women in their 40s versus a 9.4% risk among women in their 50s (Myers et al., 2015; Nelson et al., 2016b; Oeffinger et al., 2015). During biennial screening, the risk for false-positives among women in their 40s was 4.8% versus 6.4% among women in their 50s (Myers et al., 2015; Nelson et al., 2016b; Oeffinger et al., 2015). These results display that women in their 50s carry a higher risk for false-positives than those in their 40s regardless of annual or biennial screening. Therefore, the need to avoid the risk for false-positive findings with follow-up recommendation for additional imaging or biopsy remains consistent at any age and should not be a limiting factor with screening beginning at 40 versus 50 years. Factors that could contribute and affect false-positive rates include breast density, type of imaging modality used, postmenopausal hormone therapy, timing of first mammogram, interval rescreen rate, and lack of comparison mammogram images (Nelson et al., 2016b; Oeffinger et al., 2015). Modifiable and nonmodifiable risk factors are not discussed with this study and could affect these results.

Overdiagnosis

Overdiagnosis might be considered the greatest harm for a woman obtaining mammogram imaging. Overdiagnosis is defined as the diagnosis of "cancer with a screening test (such as a mammogram or Prostate-Specific Antigen test) that will never cause any symptoms. These cancers may just stop growing or go away on their own" (National Cancer Institute, n.d., para 3). The ACS, USPSTF, Myers et al. (2015), Pace and Keating (2014), and van den Ende et al. (2017) systematic reviews state that overall predication estimates for breast cancer overdiagnosis range widely from 0% to 54% due to varying measures such as the BCS practices used, disease incidence with or without screening, inclusion or exclusion of ductal carcinoma in situ, and lead time adjustments (described as the time gained before cancer incidence from early detection) (Nelson et al., 2016b; Oeffinger et al., 2015). Furthermore, no one individual has the same underlying predisposing risk factors, behavioral influences, values, socioeconomic status, and comparable access to resources. Due to the variability in estimating the impact of breast cancer overdiagnosis from mammograms, Myers et al. (2015) and Oeffinger et al. (2015) determined the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework as low. The ACS, USPSTF, Myers et al. (2015), Pace and Keating (2014), and van den Ende et al. (2017) share the understanding that it is difficult to quantify the impact of overdiagnosis because there lacks a clear consensus on the best approach of how to measure and evaluate this outcome (Nelson et al., 2016b; Oeffinger et al., 2015). Without demonstrating sound quality evidence in the rates of overdiagnosis related to BCS, it is difficult to synthesize this factor as an influence toward guideline recommendation and provider-to-patient counseling.

Psychological impact

The USPSTF considers and accounts for the potential negative psychological impact that mammography screening may have on women, as a "harm" to BCS screening (Nelson et al., 2016b). United States Preventive Services Task Force found that women who had negative mammogram results experienced less anxiety and distress than those with other outcomes (Nelson et al., 2016b). Mixed results were reported and not found significant among women not returning to their next scheduled mammogram after experiencing a previous false-positive result (Nelson et al., 2016b). Pace and Keating (2014) suggested that women with false-positive findings experienced higher levels of situational distress but did not elicit the diagnosis of major depressive or anxiety disorder. Evaluating the extent of individualized concern caused by factors from potential negative outcomes of screening is a subjective finding that is balanced differently for each patient and difficult to translate across a general population.

Mammography radiation risk

There are currently no studies that directly measure the risk of cumulative mammography radiation-induced breast cancer (Nelson et al., 2016b; van den Ende et al., 2017). Rather, the USPSTF reports modeling studies predicted that women aged 40-59 years experienced 11 per 100,000 radiation-induced breast cancer deaths and 2 per 100,000 in women aged 50-59 years (Nelson et al., 2016b). ACOG (2017) states 125 of 100,000 women receiving annual mammography between 40 and 74 years were diagnosed with radiation-induced breast cancer from mammograms that resulted in 16 deaths, but 968 breast cancer deaths were averted by screening. These estimates elude that the possibility of avoiding multiple breast cancer deaths by decreasing radiation exposure may outweigh the potential risks of mammography to screen for cancer and save other lives.

Advantages to breast cancer screening with mammography (for Women Aged 40-49 Years)

Surveillance mammograms have been identified as an effective screening tool for identifying breast cancer and when done before an individual becomes symptomatic, early stage diagnosis and successful treatment with cure is higher. If breast cancer is found to be localized at the time of diagnosis, the five-year survival rate is 98.9% (SEER, n.d.). Screening findings with advanced cancer stages has a 5-year survival rate of 28.1% (SEER, n.d.).

Earlier diagnosis stage

Mammograms conducted in women aged 40-49 years offer the opportunity to begin provider-to-patient education sooner, diagnose breast cancer earlier, treat more successfully, and reduce overall mortality (Shen et al., 2011). A 10-year retrospective study comparing women aged 40-49 years with mammography (145) and nonmammography (166) detected that breast cancer exhibited smaller average tumor diameter size (20.68 mm vs. 30.38 mm; p < .0001), less sentinel lymph node involvement (p < .0001), increased 5-year disease-free rate (94% vs. 71%), and better overall survival estimates (97% vs. 78%) (Shen et al., 2011). These statistically significant data demonstrate that women in their 40s who are at an average risk for developing breast cancer and receive mammograms earlier than the USPSTF's recommendations have better outcomes for earlier diagnosis, less reoccurrence or metastatic spread, and less mortality rates (Shen et al., 2011). Women aged 45-49 years and 50-54 years experience the same burden of disease (about 15% of years of life lost per age bracket) (Oeffinger et al., 2015). Even with this knowledge, current practice guidelines conflict and differ among each other, prohibiting a cohesive, standardized, decision-making model.

Decreased mortality

Reduced breast cancer mortality in women who begin screening with mammography in their 40s is evident across the majority of studies (Magnus et al., 2011; Myers et al., 2015; Nelson et al., 2016a; Oeffinger et al., 2015; Pace & Keating, 2014). van den Ende et al. (2017) report in their systematic review of four articles reviewing two randomized controlled trials (the Age trial and the Canadian National Breast Screening Study-I [CNBSS-1]) that there was no statistically significant difference found in breast cancer mortality among women screened between 40 and 49 years. However, van den Ende et al. (2017) identified limitations in both studies where the quality of mammogram technology and radiology interpretation in the CNBSS-1 trial were possibly substandard, and in the Age Trial, after the initial mammogram, all subsequent screenings were completed as single view instead of the standard two-view screening mammogram. van den Ende et al. (2017) is the only systematic review that found no significant evidence of breast cancer mortality reduction in women receiving routine screening for breast cancer in their 40s.

Magnus et al. (2011) completed a meta-analysis and found a 17% mortality reduction in women who had screening mammograms between 39 and 49 years. Myers et al. (2015) and Pace and Keating (2014) conduced systematic reviews to find a 15% mortality reduction among women beginning screening younger than 50 years. The USPSTF reports a breast cancer death avoidance rate of 3 per 10,000 if screening started at 40 years, compared with 8 per 10,000 fewer breast cancer deaths if starting at age 50 years (Nelson et al., 2016a). The ACS graded the outcome of reduced breast cancer mortality evidence in women younger than 50 years as high (Oeffinger et al., 2015). The 5-year absolute risk of women developing breast cancer at 5-year intervals is 0.6% during 40-44 years, 0.9% during 45-49 years, and 1.1% during 50-54 years (Oeffinger et al., 2015). Each life has significant value, and mortality reduction is clearly evident in women receiving mammograms earlier than 50 years.

Lives saved/potential years of life gained

It is undeniable that mammography is the best available diagnostic imaging modality and gold standard for detecting breast cancer (World Health Organization [WHO], 2018). Pace and Keating (2014) found in their systematic review that 5 out of every 10,000 women aged 40-49 years, 10 out of every 10,000 women aged 50-59 years, and 42 out of every 10,000 women aged 60-69 years will be saved from mammograms. The USPSTF found that using biennial mammography in women aged 40-74 years added 152 lifetime years and avoided 8 breast cancer deaths per 1,000 versus women aged 50-74 years, where 122 total years of life were gained and 7 breast cancer deaths were avoided (Sui, 2016). The ACR estimates that using their recommended screening strategy, if women received annual mammograms from 40 to 84 years, 11.9 per 1,000 breast cancer deaths were prevented and added 189 years of life (Monticciolo et al., 2017). The ACR estimates that using the USPSTF's recommendations, if women received biennial screening from 50 to 74 years, 6.95 per 1,000 were prevented and added 110 years of life (Monticciolo et al., 2017). Evidence suggests that those screened earlier and more frequently have the potential to experience lengthier lives and fewer deaths.

Evaluation

The occurrence of false-positive mammogram findings was comparable in women starting screening at 40 or 50 years (Nelson et al., 2016b; Oeffinger et al., 2015; Pace & Keating, 2014). False-positive mammograms that led to biopsy recommendation increased with age for first-time screens and 10-year cumulative screenings (Myers et al., 2015; Nelson et al., 2016b; Oeffinger et al., 2015). The highest occurrences of false-positive recalls were recorded when the interval of mammogram screening was completed annually versus biennially (Myers et al., 2015; Oeffinger et al., 2015; Nelson et al., 2016b; Pace & Keating, 2014). Studies measuring breast cancer overdiagnosis have published wide predictions that challenge the interpretation of adequately balancing the harms and benefits of screening (Myers et al., 2015; Nelson et al., 2016b; Oeffinger et al., 2015; Pace & Keating, 2014). Disseminating this information is critical in understanding the importance of including women in their decision for choosing when to begin mammography. The evaluation of any psychological stress related to BCS in the literature, especially pertaining to those who test positive, demonstrates findings of temporary levels of anxiety and distress, which is a normal reaction and probably a consistent finding in any new disease diagnosis state. There are only modeling studies representing the best available evidence to measure radiation-induced breast cancer from mammograms, and although these data are important, it is not evidence based and should be given further consideration when associating with risks during mammogram screening. The risk for false-positive recalls, overdiagnosis, risk of mammogram radiation-induced breast cancer, and psychological impact do not appear to make a significant negative impact of the BCS process.

Currently, mammography is the best available technology used to identify breast cancer (WHO, 2018). Women aged 40-49 years identified with breast cancer from mammography compared with nonmammography are found with smaller average tumor size, less sentinel lymph node involvement, higher 5-year disease-free rates, and improved overall survival (Shen et al., 2011). The number of lives saved with screening mammograms, the potential of years of life gained, and avoided breast cancer deaths are evident (Monticciolo et al., 2017; Pace & Keating, 2014; Sui, 2016). Nearly all articles found a degree of mortality reduction among women screened with mammograms during their 40s (Magnus et al., 2011; Myers et al., 2015; Nelson et al., 2016a; Oeffinger et al., 2015; Pace & Keating, 2014). The outlined benefits of screening women younger than the current USPSTF recommendations (age, 40-49 years) should be communicated to all women and their choice for when to start mammograms.

The variabilities found in positive outcomes for BCS effectiveness or risks associated with mammography for women in their fourth decade of life implicate a need for further rigorous studies to support appropriate counseling and screening guidance for women. Comparing the beneficial or "harmful" outcomes of BCS at different age brackets such 40-44 years or 40-49 years can yield differing results affecting committee panel interpretations that lead to guideline recommendations. Using data from outdated mammogram screening technology and studies conducted >10 years ago is a potential misrepresentation of current advancements in imaging accuracy of detecting breast irregularities and radiation exposure. Predisposing nonmodifiable risk factors can alter the probability and age a woman receives a breast cancer diagnosis. Behavioral and environmental influences, and breast characteristics can also affect the incidence women experience breast abnormalities results from mammograms. All reviews compared and referenced the same studies suggesting current research is limited. The available evidence also represents only partial data that requires more comprehensive research on minority and marginal populations, the impact of current technology, and advanced breast cancer treatment options to more effectively evaluate the outcomes of BCS.

Conflicting recommendations for the initial age to start mammography, the frequency, and age for discontinuation reflect a disproportionate value on women's health and foster discord among producing conformity in guidelines from governing professional organizations, uniform practice between HCP, coverage with insurances, and ultimately the provision of comprehensive and standard breast health for the female population. It is apparent that where evidence and modeling lack a clear measure of advantage or disadvantage, it is the consensus or opinion from each panel committee in their respective organizations that determines the decisions toward their final recommendations. However, how can the opinion of a single committee member or a panel determine the screening guidelines where evidence is unclear and exhibits such variability?

Discussion

After examining the varying available guidelines on BCS practices and the evidence determining these recommendations, it is critical that standard of care decision-making protocols are created to help promote and allot time for breast cancer counseling. Provider and patient discussion about individualized preventative breast health measures offers an opportunity to educate women who value the potential benefits of BCS over the risks and otherwise identify individuals who are predisposed for developing breast malignancies. Incorporating a BCS process as part of the routine well-women annual examination or inviting women eligible for screening at their primary care clinic will raise awareness and promote holistic care. The Centers for Medicare and Medicaid Services created an electronic clinical quality measure, CMS125v6, to monitor the 2018 performance of women aged 50-74 years obtaining mammograms to screen for breast cancer (Electronic Clinical Quality Improvement Resource Center, 2018). Quality measures emphasize the importance of addressing high quality assurance in health care to improve outcomes. Starting screening early in some women and ensuring that screening will happen by 50 years for all women will help providers and clinics meet the Centers for Medicare and Medicaid Services core measure goals of quality health care. Developing a standardized protocol that incorporates a process of shared decision making starting at 40 years will foster a flow for early conversation and hopefully mitigate further delays in achieving successful screening mammogram rates.

Breast cancer screening should address health as a collaborative process between provider and patient. Encouraging establishment of a comprehensive care plan and ultimately optimizing breast health outcomes for each individual patient, instead of categorizing patients into groups, can save lives. Informed consent that is based on evidence is nonbiased, and a process of shared decision making between the patient and the provider is necessary. Shared decision making considers patient values and preferences, and respects cultural practices, religious beliefs, and spiritual beliefs, and can inadvertently increase trust and strengthen the patient and provider relationship. This can open the discussion for identifying women with risk factors for breast cancer and lead to earlier opportunity of collaborating and establishing a breast health plan. Supporting patients in making informed decision regarding their breast health promotes patient-centered, autonomous care.

A sample algorithm for initiating mammograms (Figure 1) developed by the authors after careful consideration of knowledge from the systematic review and current evidenced-based practice guidelines is one example of a potential organizational tool that can help providers have a comprehensive view and approach to BCS. The Screening Mammogram Initiation Protocol (SMIP) is an evidence-based strategy for HCPs to educate and navigate women about their breast health throughout their life trajectory. It considers personalized nonmodifiable risk factors, integrates autonomous patient choices through the shared decision-making process, and encourages periodic rescreening to update any identifying high-risk women. The SMIP was developed with an intention to be used as an informative reference displaying the best available evidence that offers the opportunity to streamline BCS practices among HCP and across primary care clinics.

Figure 1. Screening mammogram initiation protocol. 1. Adapted from: American College of Obstetrics and Gynecologists: The American College of Obstetricians and Gynecologists. (2017).

Conclusions

In light of advancing technology and the shift toward precision health, primary HCPs have the opportunity to initiate the discussion and counsel women on the risks, benefits, and limitations of BCS while incorporating patient values and preferences. There is an opportunity to promote BCS in various populations and decrease health disparities using primary care practice tools, such as the SMIP. National goals to increase BCS interventions can be met and positively influence quality health care outcomes, screening efficiency, delivery of care, financial performance, and patient-provider satisfaction. Shared decision making between provider and patient coupled with standard breast screening guidelines can ultimately empower women about breast health and improve patient outcomes.

References