Of Mammograms and Uncertainty

In medical school, I was told medicine is an art and not just a science. In residency, I learned that the art is inexact and that uncertainty is part of life for physicians. 

One patient who taught me deeply about the latter was a young woman who had come to see me for her annual check-up. She was a regular clinic patient with excellent insight into her health—one who often helped people in her church navigate their complicated medical issues, and one I saw for social visits as much as medical. She would always minimize her health literacy, saying, “I’m just a high school grad,” but I always told her she had good instincts and that I trusted her judgment, too. As physicians, it is important to have a collaborative approach on health care decisions, and I always felt this way with my patient.

During her appointment, we discussed whether she needed a mammogram that year. She did not have any risk factors that would require her to get an annual mammogram, so I told her it was not entirely necessary that she get one that year, but we could discuss risks and benefits and make a decision together. Using the collaborative approach, we decided to order the mammogram.

After our patient visits, we often wonder whether we did right by our patients. In this case, I was upset I could not give the patient an absolute "yes" or "no" to the mammogram questions. But in speaking to my mentors in clinic, I realized that this is a feeling that all physicians have and that collaboration was important. Still, in these moments of certainty, it is helpful to lean on evidence. I ordered the mammogram for the patient, and after doing so, I began looking into studies to determine if what I had done was right or wrong.

A 2014 ACP Journal Club summary noted that among women aged 40 to 59 years, “annual screening with mammography for 5 years does not reduce long-term risk for breast cancer mortality more than usual care or annual screening without mammography" (1). So we may diagnose the cancer, but ultimately it may not affect mortality. Reading this made me feel a little better, knowing that mortality may not be affected by annual mammograms.

A more recent article in Annals of Internal Medicine helps address the screening question further (2). As the authors noted, “annual screening has a favorable balance of benefits and harms and would be considered cost-effective for subgroups of women aged 50 years with risk levels that are 2 to 4 times the average and that have heterogeneously or extremely dense breasts.” I now have justification in one scenario in which annual mammograms are needed. On the basis of this study, in women with low risk and nondense breast tissue, mammograms could even be spaced out to triennially.

I find it helpful to have these facts behind me in ordering or not ordering mammogram testing. Knowing them now, I think I would have still recommended the mammogram because she does have a history of dense breast tissue.

About a month after our visit and after my research and conversations with my mentors, the mammogram results came back abnormal: She had aggressive but treatable hormone-positive breast cancer. At our subsequent visits, we set her up with oncology and surgery teams. She went through a year of surgeries, chemotherapy, and radiation and was ultimately cancer-free. After my experience with her, I struggled with balancing evidence and my anecdotal experience. How much should I let this possible-miss influence my practice? And would it even have been meaningful based on the studies I read? I waited until her treatment was over before I asked the patient her thoughts. I told her had we not used the collaborative approach, I may not have ordered the mammogram that year, and that I was glad we got it done.  She told me, “I don’t know, it’s been a tough year.”

Knowing that the patient ended up having cancer, I went back to my clinic preceptors and asked them whether, given that the patient ended up having cancer and knowing the information presented in Annals, they were going to recommend women get annual mammograms. It was clear this was a difficult question to answer, given the situation with my patient. Most of my mentors said they still would use evidence and a collaborative approach with the patient. They do not feel compelled to order a test based on the experience of one patient alone.

I have since asked myself the same question, and while I carry my experience with my patients with me, I do not have an explicit "yes" or "no" when it comes to mammograms. It remains a discussion. I explain that annual mammograms in low-risk cases do not always have mortality benefits. However, I gauge the situation with my patients, and ultimately, I think we discuss together what the best decision is.  The conversation between patient and physician is perhaps the epitome of the art of medicine. Since beginning the clinical practice of medicine, I have realized that nothing is certain, collaboration is a good approach, and guidelines are helpful but situational. When it comes to breast cancer screening with mammography, it is a conversation.

References

1. Fletcher SW. ACP Journal Club. Annual mammography screening did not reduce long-term breast cancer mortality in women 40 to 59 years of age. Ann Intern Med. 2014;160:JC7. [PMID: 24842441] doi:10.7326/0003-4819-160-10-201405200-02007
2. Trentham-Dietz A, Kerlikowske K, Stout NK, Miglioretti DL, Schechter CB, Ergun MA, et al; Breast Cancer Surveillance Consortium and the Cancer Intervention and Surveillance Modeling Network. Tailoring breast cancer screening intervals by breast density and risk for women aged 50 years or older: collaborative modeling of screening outcomes. Ann Intern Med. 2016;165:700-12. [PMID: 27548583] doi:10.7326/M16-0476