The Critical Role of OB-GYN Providers and Primary Care Physicians in Breast Care
The recommended frequency of breast cancer screening and the age at which a woman should begin mammography remain sources of considerable debate. Becoming less contested is the role breast density plays in a woman’s risk for developing breast cancer, as it is now acknowledged as an independent risk factor.
Greater breast density not only increases a woman’s risk, it can also mask or hide tumors, making it more difficult for radiologists to detect cancer by mammography alone. A woman with dense breasts may benefit from supplemental screening such as ultrasound or MRI for a radiologist to detect cancer earlier.
How are women informed of their breast density? And once they know it, what does it mean and what are they to do?
While 38 states in the United States have laws in place stating women are to be informed if they have increased breast density, the language and governance differ state-by-state. Recently, the US Food and Drug Administration (FDA) proposed a national rule that would inform women of their breast density to “help empower patients with more information when they are considering important decisions regarding their breast health care.” But the key to both questions lies in the role that OB-GYN providers or primary care physicians (PCPs) play in women’s healthcare, specifically breast care.
Evidence-Based Support for the Impact of OB-GYN Providers and Primary Care Physicians
A recent study demonstrated that frequent interaction with PCPs can have a positive influence on patients’ compliance to screening mammography.
Another study showed that patients diagnosed with breast cancer, whose OB-GYN providers were advocates for the importance of breast cancer treatment, were at lower risk of discontinuing treatment compared to patients without this support. The study gave this conclusion:
Clear communication of the seriousness of the situation, the usefulness of the treatment, and its side effects is important. . . . The patient must accept the treatment and be convinced of its benefits as factors positively influencing compliance. In addition, she must be satisfied with the medical advice and care and should receive support from her social environment. A poor doctor-patient relationship, lack of confidence in the doctor or treatment, insufficient information, or problems with taking the medication are again considered as factors negatively influencing compliance.
Of course, adherence to screening and treatment has an impact in the mortality rates from breast cancer. In the United States, breast cancer mortality rates have decreased by 1.8% to 3.4% per year since 1990. In the European Union, breast cancer deaths went down by 16.4% between 1989 and 2019 for the age group covered by screening.
Physician and Patient Education Efforts
OB-GYN providers’ and PCPs’ influence on patients’ screening and treatment compliance and outcomes indicates that these physicians are well positioned to be the patient educators on breast density and the screening protocols for dense breasts. However, these providers have not been trained extensively on what breast density means for their patients.
Organizations such as DenseBreast-Info have been educating physicians for many years on the importance of breast density so that patient and providers can have an informed conversation. JoAnn Pushkin, co-founder of the organization and a breast cancer survivor, has witnessed the effects that the lack of education can have for both the patient and the provider. As JoAnn shares:
After the New York inform law went into effect in 2013, I began to hear from women who were getting the new breast density notification in their post-mammography letters but were hitting a brick wall trying to get more information on the topic from their referring providers. Am I at high risk for developing breast cancer? Should I insist on an MRI even if I have to pay out of pocket? Should I stop getting mammograms entirely? Is breast density a diagnosis? One woman’s referring provider told her the only reason she was being told about her breast density was because Gov. Cuomo had “signed some stupid law” and that she didn’t really need to know anything about it. Another was told that although her breasts were “extremely dense,” the mammogram report received from the imaging center said results were “normal” and so there was no need to discuss the benefits of supplemental screening. It became clear that “informed” did not mean “educated” and a medically sourced resource was needed for everyone involved in a woman’s mammogram—both the patient and those to whom she turned for information, her providers.
Providers who participated in a comprehensive CME/CE course, Breast Density: Why it Matters (2 AMA/PRA 1 or 2 ARRT A credits) were asked to relate the drawbacks of inadequate education as well as the benefits they received from learning more about breast density. Their comments included the following:
Deficiencies Listed Prior to Breast Density Education
- “As an ob/gyn, [I] had minimal to no training in breast imaging.”
- “[I] did not know info on interval cancers, did not know all the factors of risks.”
- “[I] did not know that Gail scores should not be utilized for determining MRI surveillance candidates.”
- “[I] was not aware of the other screening tools.”
Key Benefits of Breast Density Education
- “When I give patients their results, I am better able to explain what the BI-RADS Categories and Density categories mean.”
- “[I am] able to speak more specifically to the differences in screening modalities being recommended to patients.”
- “Better understanding of how density affects breast imaging. More comprehension of different imaging options.”
- “Gave me a better understanding of why some screening methods were better than others based on the patients’ personal risk factors.”
- “I can reiterate the importance of having a yearly screening mammogram to my patients, especially those with dense breasts, and be confident with my answers to their questions.”
Fostering the Conversation
The American College of Obstetricians and Gynecologists (ACOG) has taken an important step in fostering the conversation between physicians and patients. ACOG is encouraging its members to discuss screening choices with patients: “Given the range of current recommendations, we have moved toward encouraging obstetrician-gynecologists to help their patients make personal screening choices from a range of reasonable options. . . . ACOG recommends that women and their ob-gyns engage in a dialogue that includes discussion of the woman’s health history; the benefits and harms of screening; and the woman’s concerns, priorities, values and preferences about the potential benefits and harms of screening.”
However, the ACOG guidance needs to be more explicit and include the topic of breast density. Understanding breast density is critical in providing a personalized screening plan that meets the woman’s needs. At a time where over 100 OB-GYN practices1 are providing mammography services, educating OB-GYN providers on the risks faced by women with dense breasts is an important initiative.
Another recently issued guideline statement by the American College of Physicians (ACP) also promotes “shared decision-making” between patients and physicians regarding screening. Putting aside the recommendation on screening guidelines around age and frequency, the guideline classified high breast density as an average risk even though women with dense breasts are 4 to 6 times more likely to develop breast cancer when compared to women with fatty breasts. It also fails to point out that in order to have a meaningful decision-making conversation about the screening age and frequency, a woman needs to know her risk factors. Breast density can only be determined via a mammogram.
A new research study is being conducted “to evaluate the effect of an educational intervention on primary care providers’ knowledge of breast density and its implications for breast cancer screening and risk, as well as their comfort level navigating patient discussions around the topic.”
The study will fuel further conversation not only between patients and providers but also among all organizations that provide physician support and objective data required to educate and counsel patients appropriately. Increasing physicians’ knowledge on the importance of breast density and equipping them for dialogue with their patients, will encourage women to follow a personalized breast health plan that includes screening protocols tailored to their individual breast cancer risk.
1. Based on analysis of the MQSA database.