Conflicting breast cancer screening guidelines: What’s an MD to do?

Four respected organizations are promoting different guidelines for routine breast cancer screening. The conflicting recommendations place physicians in a bit of a quandary as the broad set of valid options may leave clinicians feeling vulnerable to malpractice suits. A viewpoint published online May 30 in JAMA sorted through the guidelines and offered some suggestions.

Allen Kachalia, MD, JD, and Michelle M. Mello, JD, PhD, both of Harvard School of Public Health in Boston, dissected the inconsistent recommendations regarding the appropriate interval for screening mammography for women aged 40 to 74 years and whether clinical breast exam (CBE) should be performed.

The American College of Radiology and American Cancer Society (ACS) recommend annual screening mammography for women aged 40 and older, with ACS supporting CBE “preferably annually.” The U.S. Preventive Services Task Force (USPSTF) guidelines recommend biennial screening mammography for women aged 50 to 74 years. The American College of Obstetricians and Gynecologists guidelines support annual CBE and suggest offering annual mammography but state biennial exams may be “more appropriate or acceptable” for some women.

Consequently, physicians who refer to guidelines supporting less frequent screening as outlined by the USPSTF guidelines may feel they are exposed to greater malpractice risk, according to Kachalia and Mello. “The dilemma is intensified if the radiologist interpreting the patient’s last screening mammogram, relying on American College of Radiology guidelines, recommended annual screening to the patient despite no concerning findings.”

The authors noted, “Guidelines are designed to synthesize evidence and promote adherence to evidence-based courses of treatment about which expert bodies in the medical community have reached agreement.” Although they are not intended to establish legal standards and the basis for negligence in malpractice suits, physicians may pause at veering from guidelines.

However, in the case of breast cancer screening, deviation from guidelines is unavoidable.

Kachalia and Mello attempted to allay clinicians’ concerns with a few suggestions, including:

• Educating patients about the existence of conflicting guidelines and the lack of one “right” answer; and
• Documenting the rationale for the recommendation and discussion with the patient in the medical record.

The authors also emphasized that most malpractice claims for missed or delayed diagnosis of breast cancer related to “failure to order proper evaluation of known clinical abnormalities (e.g., palpable lumps) or mammographic abnormalities.”

They recommended that physician practices, hospitals and health systems could support physician discretion in use of various guidelines by ensuring consistent recommendations by all providers in the system. Finally, the authors noted that state legislatures could pass “safe harbor” legislation that provides liability protection to physicians who use approved guidelines or protocols.