One of the hardest things a physician must do is provide accurate, balanced counseling to their patients, particularly regarding controversial subjects. We are inundated everyday with new research and recommendations. On top of this, the imperative to practice evidence-based-medicine grows everyday. So what is a responsible physician to do? How is it possible to discuss the nuances of various research studies, particularly when they are at odds with the guidelines issued by our professional associations, all in the 15 minutes allotted for the annual visit that year? To say that it is challenge would be an understatement.
Back when I started residency, a mere 13 years ago, every woman received a pap smear every year to screen for cervical cancer. There was no need to even think about it, nor anything to discuss aside from when the patient would receive the results. With that, the visit was complete only to be repeated the following year.
As it stands now, they guidelines for pap smears are changing with startling frequency. Now, a physician must not only assess each patient individually to determine their need for a pap smear, but they must also explain to the vast majority of patients why they are no longer in need of what was once a yearly staple in their quest for health prevention. And did I mention that this all needs to be done in the same 15 minute visit as before when no explanations were necessary?
And of course patients have questions. As physicians we have touted the pap smear as one of the single greatest accomplishments of the 20th Century, amazing for its ability to detect precancerous cells and to prevent the woman from developing cervical cancer. All true. However, now that more is known about the Human Papilloma Virus (HPV) and it’s role in cervical cancer, the game has changed. But at least it is a change that everyone supports—the researchers, the professional organizations, the insurance companies, the doctors—not just for the tremendous cost savings, but that is certainly one of the motivators.
An NPR blog post entitled “Are We Paying $8 Billion Too Much for Mammograms?” highlights the conflict between cancer detection and cost with regard to breast cancer screening that has culminated into an untenable position for physicians. The blog is based on a cost analysis published this month in the Annals of Internal Medicine. In that article, the authors compare cost of following the American Cancer Society recommendations (annual mammography at age 40) with the cost of following the U.S. Preventative Task Force guidelines (biennial mammograms from ages 50 to 74 with risk factor determination for women under 50 and over 74). The authors conclude that the difference in approach totals approximately $6.5 billion per year.
While a novel approach to breast cancer screening may be adopted in certain physician circles, Gynecologists are far more likely to follow the recommendations of their parent organization, The American College of Obstetricians and Gynecologists (ACOG). While not addressing the cost analysis addressed in the recent blog post, ACOG has recently released a reaffirmation of the recommendation to begin annual mammography for women at average risk for breast cancer following a study in the British Medical Journal that found screening mammography did not decrease deaths from breast cancer in women aged 40-59 beyond physical examination and usual care. ACOG continues to recommend annual screening from age 40 based on concerns over the methodology of the study at a cost of $10 billion annually.
So what does that mean for the traditional annual examination? As of right now, it means that we need to be prepared to spend more time talking to our patients at our annual visits. And while that is not a bad thing, when you go for your exam you should definitely bring a book. You might be waiting a while.
Dr. Susan Raine is Program Director and Vice Chair of Education at the Baylor College of Medicine Obstetrics & Gynecology