Going against the status quo in screening

Case description

Bara is a 54-year-old woman who has been a patient in your practice for several years. She recently received a letter from the provincial government’s breast screening program indicating that she is overdue for breast cancer screening with mammography. Although Bara has no family history of breast cancer, she is quite anxious because one of her close friends was recently diagnosed with breast cancer. Her friend has responded well to treatment and believes this is primarily because of early diagnosis by mammography. Bara is quite upset that she did not have a referral for a mammogram earlier and that she had not been advised she should have mammograms annually to screen for breast cancer. Bara would like an urgent appointment with you to discuss a referral for mammography.

You reflect on your impending visit with Bara and the information you need to have for an informed discussion. You also consider how best to undertake this discussion, especially given Bara’s request for more frequent than recommended screening. What information and tools on the potential benefits and harms of mammography will you need? What would you do? Clinical and educational issues resulting from Bara’s concerns are outlined in Table 1.^13-17

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Table 1.

Examples of clinical and educational issues arising from the patient’s concerns

What factors need to be addressed to improve foundational skills in screening?

The current approach to screening often follows a simple, linear, checklist format. In reality, preventive care is a complex and adaptive process involving physician, patient, and environmental factors.¹⁸ The complexity is multifactorial and is based on challenges pertaining to understanding core screening concepts, a frequent lack of integration of patient preferences and values in the decision-making process, social media misinformation, and the multiplicity of guidelines and an inability to consider them critically. Conflicts of interest, gaps in knowledge, or an absence of rigour in the evidence underlying recommendations often result in confusion. This confusion contributes to the inappropriate and inconsistent application of screening recommendations.¹⁹ Many provinces have adopted direct-to-patient communication and notification regarding screening for breast, cervical, and colorectal cancer.²⁰ Direct-to-patient screening does not address each patient’s unique circumstances, assumptions, and understanding of preventive care, which may be predicated on social media myth, and it fails to leverage the opportunity to address modifiable risk factors that contribute to disease.^21,22 This failure is magnified at the clinician teacher–learner-patient interface, where factors such as perceived lack of time, statistical illiteracy,¹¹ lack of critical thinking,^10,12 fear of missing a diagnosis, fear of legal repercussions, and perceived patient preferences (to test just to make sure) all complicate the screening decision process for physicians and trainees alike.

Physicians, medical trainees, and patients potentially all have different understandings of key screening concepts, making appropriate and informed decision making challenging.^23,24 It is important to emphasize that screening guidelines are not rules, and that using them properly requires understanding the evidence behind them. Critical thinking skills are key to understanding how to communicate screening to patients (such as using infographics and decision aids) through a shared decision-making approach.^2,25,26

How do we improve physician skills in screening?

Physicians and other health care providers are faced with 2 main educational challenges in attempting to improve knowledge and skills to foster more appropriate screening. The first challenge is the development of educational content on key concepts related to screening (Table 2).^21,27-29 The Prevention in Practice series published in Canadian Family Physician provides useful content for physicians and other health care providers.^25,30 A more detailed outline of the skills needed for screening will be found in a subsequent paper in this series.

The second challenge is the development of educational strategies to bring the teaching and uptake of these concepts into the core of medical education at the levels of the medical student, resident, and practising physician. Family physicians and other health educators will need to consider carefully how to best teach these skills and integrate them into routine practice. Some examples of how this might occur are outlined in Table 3.¹⁰ Educational strategies are necessary, but they alone may not be sufficient. Knowing the information does not always translate to applying the information. Lessons learned from the lack of success in teaching evidence-based medicine need to be considered.^9-11 Meaningful change requires system-level changes that align with the educational strategies suggested in Table 3¹⁰ and help clinician teachers, learners, and patients better understand screening.^7,8,25,31

Case resolution

In preparation for Bara’s visit, you review the Canadian Task Force on Preventive Health Care (CTFPHC) guideline that recommends screening for breast cancer every 2 to 3 years with mammography.¹⁴ You realize it does not give much detail on why it recommends that interval. You also review a US modeling study comparing different screening intervals.³²

Bara attends your office a few days later. You review with her the national guideline that recommends screening for breast cancer every 2 to 3 years with mammography. She remains unconvinced; she has found recommendations online from professional organizations and advocacy groups that recommend annual screening. You acknowledge her concerns and indicate that you are aware of different guideline recommendations on screening for breast cancer. Although you raise the issue of harms related to screening, Bara indicates that it “only makes sense” that more frequent screening has a better chance of finding early breast cancer. You acknowledge that it appears to make sense that more frequent testing likely will find more; the question is how much difference that makes to a patient’s life versus how much more harm may occur. You discuss the information on the decision aid from the CTFPHC. She has trouble understanding the concept of overdiagnosis, so you do your best to explain it. After this discussion, Bara still wishes to have annual screening.

You give Bara a requisition for a mammogram and a copy of the CTFPHC infographic, and you invite her to discuss her desire for annual screening next year. After the visit you remain troubled; you are not sure why the guideline recommendations are different, and you wonder if you could have done a better job of communicating the benefits and harms to Bara.

Call to action

Clinician teachers, learners, professional societies that develop guidelines,^33,34 screening agencies, and academic institutions should reconsider the optimal approach to the uptake and implementation of guidelines. This change in focus should encompass the breadth of learners from undergraduate medicine to continuing professional development as well as the breadth of stakeholders from patients to agencies. Now is the time to swim against the tide and reconsider our approaches to teaching and communicating prevention and screening information, and to ensure they encompass an understanding of complexity, core concepts, and best practices.