What’s the Point?

As a practicing internist, a question I often ask myself before ordering a test or making a recommendation to a patient is, “What’s the point?” Why do I need to treat your diabetes, Mr. S? Because we want to prevent a heart attack or stroke. Why do we need to check a dual-energy x-ray absorptiometry scan, Ms. B? Because I want to make sure we’re optimizing your bone health so you don’t have a hip fracture. Why am I ordering this study? Because it will help inform diagnosis and a treatment plan. In asking these questions, I try to make sure my clinical practice is grounded in value-based care—that what is ordered or intervened on is truly necessary, helpful in the patient’s care, and cost-effective.

For me, when I read scientific studies, it is always through the lens of, "How does this apply to me practically?" In “Incorporating Baseline Breast Density When Screening Women at Average Risk for Breast Cancer: A Cost-Effectiveness Analysis” by Shih and colleagues (1), the authors explore breast cancer screening and dense breast tissue. In the study, patients are stratified into dense and nondense breast tissue groups. Dense breast tissue groups get annual mammography per most recommendations, and nondense breast tissue groups get mammography every other year. The study found “that a baseline breast density assessment at age 40 years, followed by annual screening for women with dense breasts and biennial screening starting at age 50 for women without dense breasts, is likely to be cost-effective. Compared with other screening strategies examined in our study, this strategy is associated with the greatest reduction in breast cancer mortality and is cost-effective but involves the most screening mammograms in a woman's lifetime and higher rates of false-positive results and overdiagnosis.” Essentially, what this means for patients is that those with dense breast tissue benefit from annual mammography, whereas those without dense breast tissue do not need annual screenings. In doing so, there are less false-positive results. Of course, there are data and guidelines that advocate for both annual screening and more spaced out screening for breast cancer, but I found this study empowering as a clinician. I have clearer information to tell patients based on this study. I can say clearly to a patient without dense breast tissue that they may not need annual screening. Similarly, I can say to a patient with dense breast tissue that annual screenings are both cost-effective and reduce mortality from breast cancer. It helps to be informed when talking to patients, and this is a helpful study for the primary care physician.

References 

1. Shih YT, Dong W, Xu Y, et al. Incorporating baseline breast density when screening women at average risk for breast cancer. A cost-effectiveness analysis. Ann Intern Med. 2021. [PMID: 33556275] doi:10.7326/M20-2912