医师的乳腺癌筛查推荐意见随指南而改变：全国问卷调查结果
编者按：2017年4月7日，中国临床肿瘤学会（CSCO）在北京发布《乳腺癌诊疗指南》，编者目前尚未查到该指南全文，尚不知与中国抗癌协会《乳腺癌诊治指南与规范》等国内外乳腺癌指南有何异同，但是不得不慨叹：吾生也有涯，而“指南”也无涯，以有涯随无涯，殆已！同样，美国的临床医师也面临着不同专业学会和组织层出不穷的各种指南，何去何从，非常值得进行调查分析。
2017年4月10日，《美国医学会杂志内科学分册》在线发表约翰霍普金斯大学、布隆博格公共卫生学院、约翰霍普金斯医学院、兰德智库的研究报告，采用问卷调查了医师随最新指南而变化的乳腺癌筛查推荐意见。
兰德智库（RAND Corporation）虽名称冠有公司（Corporation），但实际上是非营利组织，是旨在通过慈善、教育和科技促进未来美国公众福利、提高社会安全的非盈利性组织，其前身为美国空军1945年立项的兰德计划，在其成立之初主要为美国军方提供调研和情报分析服务。当时的道格拉斯飞机公司承接了这个项目。同年，兰德计划发表了《环球航天飞机实验计划的初步构想》。1948年5月，兰德获得福特基金会资助从道格拉斯公司中脱离出来，成为一个独立的智库组织。其后，这个组织逐步扩展，并为其他政府以及团体提供服务。
不同专业学会和组织对于乳腺癌筛查摄片最佳起止时间和最佳筛查间隔一直存在分歧：
2015年10月，美国癌症学会（ACS）修订其指南，鼓励40～44岁女性进行个体化筛查决策，45岁开始进行每年筛查，≥55岁女性每两年进行一次筛查【1】。
2016年1月，美国预防服务工作组（USPSTF）重新发布其推荐意见，推荐40～49岁女性进行个体化筛查决策，50～74岁女性每两年进行一次乳腺摄片【2】。
2011年8月，美国妇产科医师大会（ACOG）推荐≥40岁女性每年进行乳腺摄片【3】。
由于医师的推荐意见是患者获得筛查的最重要决定因素【4】，故该研究根据最新指南变化在全国样本中调查了医师的推荐意见。
乳腺癌学会网络（CanSNET）研究是一项针对初级保健医师（包括内科和家庭/全科医师以及妇科医师的乳腺癌筛查实践全国调查，于2006年5～9月从美国医学会医师总档案随机抽样2000位医师邮寄调查问卷，若这些医师报告向≥40岁女性提供初级保健或普通妇科医疗则符合要求，询问其通常是否建议不同年龄组的无乳腺癌家族史且无乳腺疾病史女性进行常规筛查乳腺摄片及其间隔时间，并不明确询问医师是否进行个体化决策，医师也指出了其最信任组织的筛查指南。
该研究针对各个指南关于40～44、45～49、≥75岁女性的分歧，进行了双变量分析，以评定筛查推荐意见与（1）医师专业和（2）组织信任之间的相关性。该研究获得约翰霍普金斯大学伦理审查委员会批准。
排除不符合要求的参与者后，经过校正的调查问卷回复率为52.3%（871/1665）。医师平均年龄为52.9岁，其中大多数为男性（54.6%）和非西班牙裔白人（70.6%）。家庭/全科、内科、妇科医师分别占44.2%、29.7%、26.1%。一半以上医师有超过20年临床经验。未回复者主要为男性和内科医师。
总体而言，分别有81%、88%、67%的医师推荐40～44、45～49、≥75岁女性进行筛查。与内科（IM）和家庭/全科（FM/GP）医师相比，妇科（G）医师较多推荐所有年龄组女性进行筛查（P＜0.001）（图1）。在推荐筛查的临床医师中，大多数（分别占62.9%、66.7%、52.3%）推荐40～44、45～49、≥75岁女性每年检查。
超过四分之一（26.0%）的医师最信任ACOG指南，23.8%信任ACS指南，22.9%信任USPSTF指南。信任ACS和ACOG指南的医师与信任USPSTF指南的医师相比，较多推荐筛查（图2）：
40～44岁女性：ACS指南86.5%、ACOG指南92.9%、USPSTF指南60.8%
45～49岁女性：ACS指南94.7%、ACOG指南95.6%、USPSTF指南72.4%
≥75岁女性：ACS指南73.4%、ACOG指南78.3%、USPSTF指南44.2%
因此，该研究在有代表性的全国医师样本中，发现大部分初级保健医师和妇科医师推荐≥40岁女性进行筛查。该研究结果与2014年4个临床网络的初级保健医师问卷调查大致相符，其中推荐筛查的医师比例相似，而且妇科医师的推荐率较高【5】。此外，根据医师最信任指南的推荐意见有巨大差异，这可能表明当前实践反映了对指南的不同依从性以及指南信任度的差异。该结果为指南不断发展提供了重要的参考基准，并印证了有必要阐明在临床实践中实施指南的阻碍因素和促进因素。
对此，旧金山加利福尼亚大学、旧金山退伍军人医疗中心的学者和《美国医学会杂志内科学分册》编辑发表同期述评：医师对乳腺癌筛查指南推荐意见的依从性。
参考文献
Oeffinger KC, Fontham ETH, Etzioni R, et al; American Cancer Society. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 2015;314(15):1599-1614. DOI: 10.1001/jama.2015.12783
Siu AL; U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(4):279-296. DOI: 10.7326/M15-2886
American College of Obstetricians-Gynecologists. Practice bulletin no. 122: Breast cancer screening. Obstet Gynecol. 2011;118(2, pt 1):372-382. DOI: 10.1097/AOG.0b013e31822c98e5
Peterson EB, Ostroff JS, DuHamel KN, et al. Impact of provider-patient communication on cancer screening adherence: a systematic review. Prev Med. 2016;93:96-105. DOI: 10.1016/j.ypmed.2016.09.034
Haas JS, Sprague BL, Klabunde CN, et al; PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) Consortium. Provider attitudes and screening practices following changes in breast and cervical cancer screening guidelines. J Gen Intern Med. 2016;31(1):52-59. DOI: 10.1007/s11606-015-3449-5
JAMA Intern Med. 2017 Apr 10. [Epub ahead of print]
Physician Breast Cancer Screening Recommendations Following Guideline Changes: Results of a National Survey.
Radhakrishnan A, Nowak SA, Parker AM, Visvanathan K, Pollack CE.
Johns Hopkins University, Baltimore, Maryland; RAND Corporation, Santa Monica, California; RAND Corporation, Pittsburgh, Pennsylvania; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Johns Hopkins School of Medicine, Baltimore, Maryland.
This study used a survey to investigate physician recommendations for breast cancer screening in light of recent guideline changes.
Different professional societies and organizations continue to disagree over the optimal time to initiate and discontinue breast cancer screening mammography and the optimal screening interval. In October 2015, the American Cancer Society (ACS) revised its guidelines, encouraging personalized screening decisions for women ages 40 to 44 years followed by annual screening starting at age 45 years and biennial screening for women 55 years or older.[1] The US Preventive Services Task Force (USPSTF) reissued its recommendations in January 2016 recommending personalized screening decisions for women ages 40 to 49 years followed by biennial mammograms for women ages 50 to 74 years.[2] The American Congress of Obstetricians and Gynecologists (ACOG) recommends yearly mammograms for women 40 years or older.[3] With physician recommendations the most important determinant for patients obtaining screening,[4] we investigated physician recommendations in light of recent guideline changes in a national sample.
METHODS
The Breast Cancer Social Networks study (CanSNET) is a national survey of primary care physicians (PCPs), including internal medicine (IM) and family medicine/general practice (FM/GP) physicians, and gynecologists about their breast cancer screening practices. Mailed surveys were sent to 2000 physicians randomly sampled from the American Medical Association Physician Masterfile from May to September 2016. Physicians were eligible if they reported providing primary care or general gynecologic care to women 40 years or older. The survey asked whether they typically recommended routine screening mammograms to women with no family history of breast cancer and no prior breast issues in different age groups and at what intervals; it did not ask explicitly about whether physicians engaged in personalized decision making. Physicians also indicated which organization's screening guidelines they most trusted.
We conducted bivariate analyses to assess the associations between screening recommendations and (1) physician specialty and (2) organizational trust. We focused on women ages 40 to 44 years, 45 to 49 years, and 75 years or older, where guidelines are discordant. The Johns Hopkins University institutional review board approved this study.
RESULTS
After excluding ineligible participants, the adjusted response rate was 52.3% (871 of 1665). The average age of physicians was 52.9 years, with most (54.6%) being male and non-Hispanic white (70.6%). Family medicine/general practice physicians comprised 44.2% of the sample, 29.7% were IM physicians, and 26.1% were gynecologists. More than half of physicians had over 20 years of experience in practice and were employed in physician-owned practices. Nonresponders were more likely male and IM physicians.
Overall, 81% of physicians recommended screening to women ages 40 to 44 years, 88% to women ages 45 to 49 years, and 67% for women 75 years or older. Compared with IM and FM/GP physicians, gynecologists were more likely to recommend screening for women of all age groups (P<.001) (Figure 1). Among clinicians who recommend screening, most recommend annual examinations: 62.9% for women ages 40 to 44 years, 66.7% for women ages 45 to 49 years, and 52.3% for women 75 years or older.
More than a quarter of physicians (26.0%) reported trusting ACOG guidelines most; 23.8%, ACS guidelines; and 22.9%, USPSTF guidelines. Physicians who trusted ACS and ACOG guidelines were significantly more likely to recommend screening younger women compared with those who trusted USPSTF guidelines (ACS guidelines, 86.5%; ACOG guidelines, 92.9%; USPSTF guidelines, 60.8% for women ages 40-44 years; and ACS guidelines, 94.7%; ACOG guidelines, 95.6%; USPSTF guidelines 72.4% for women ages 45-49 years) (Figure 2). This pattern was similar among women 75 years or older (ACS guidelines, 73.4%; ACOG guidelines, 78.3%; USPSTF guidelines, 44.2%) (Figure 2).
DISCUSSION
In a nationally representative sample of physicians, we found that PCPs and gynecologists largely recommended screening to women 40 years or older. Our findings are largely consistent with a 2014 survey of PCPs from 4 clinical networks where similar proportions of physicians recommended screening with higher rates noted among gynecologists.[5] We also found sharp differences in recommendations based on which guidelines physicians trusted most, which may suggest that current practices reflect both varying adherence to guidelines as well as differences in which guidelines are trusted. The results provide an important benchmark as guidelines continue evolving and underscore the need to delineate barriers and facilitators to implementing guidelines in clinical practice.
REFERENCES
Oeffinger KC, Fontham ETH, Etzioni R, et al; American Cancer Society. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 2015;314(15):1599-1614. DOI: 10.1001/jama.2015.12783
Siu AL; U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(4):279-296. DOI: 10.7326/M15-2886
American College of Obstetricians-Gynecologists. Practice bulletin no. 122: Breast cancer screening. Obstet Gynecol. 2011;118(2, pt 1):372-382. DOI: 10.1097/AOG.0b013e31822c98e5
Peterson EB, Ostroff JS, DuHamel KN, et al. Impact of provider-patient communication on cancer screening adherence: a systematic review. Prev Med. 2016;93:96-105. DOI: 10.1016/j.ypmed.2016.09.034
Haas JS, Sprague BL, Klabunde CN, et al; PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) Consortium. Provider attitudes and screening practices following changes in breast and cervical cancer screening guidelines. J Gen Intern Med. 2016;31(1):52-59. DOI: 10.1007/s11606-015-3449-5
PMID: 28395005
DOI: 10.1001/jamainternmed.2017.0453
JAMA Intern Med. 2017 Apr 10. [Epub ahead of print]
Physician Adherence to Breast Cancer Screening Recommendations.
Grady D, Redberg RF.
University of California, San Francisco, San Francisco; San Francisco VA Medical Center, San Francisco, California; Editor, JAMA Internal Medicine.
PMID: 28395063
DOI: 10.1001/jamainternmed.2017.0458