Do physicians tailor their recommendations for breast cancer risk reduction based on patient's risk?

Abstract

Objective: To investigate how physicians tailor their recommendations for breast cancer prevention and risk reduction.

Design: Cross-sectional, mail survey.

Participants: Random sample of primary care physicians in California (N = 822).

Measurements and main results: Six standardized patient scenarios were used to assess how women's breast cancer risk factors influence physicians' recommendations for screening mammography, counseling about lifestyle behaviors, genetic testing, the use of tamoxifen, prophylactic surgery, and referral to a breast specialist. Over 90% of physicians endorsed mammography for all of the scenarios. Similarly, approximately 80% of physicians endorsed counseling about lifestyle factors for all of the scenarios. Five-year risk of developing breast cancer and family history were both strongly associated with each of the 6 recommendations. Importantly, however, physicians were more likely to endorse the discussion of genetic testing, the use of tamoxifen, and prophylactic surgery for women with a family history of breast cancer compared with women at a higher risk of developing breast cancer but without a family history. Obstetrician-gynecologists were more likely to endorse most of these practices compared with internists.

Conclusions: Mammography and counseling about lifestyle behaviors are widely endorsed by physicians for breast cancer prevention and risk reduction. Whereas physicians are generally able to tailor their recommendations for prevention and risk reduction based on risk, they may perhaps underutilize genetic evaluation and newer therapeutic options for primary prevention for women who are at high risk of developing breast cancer but do not have a family history.

FIGURE 1

Percentage endorsement of breast cancer prevention recommendations for clinical scenarios. Mammography: all scenarios significantly different from scenario D. Scenarios E and F also differed significantly (all P < .001). Lifestyle: scenario A significantly different from scenarios C and D; scenario B significantly different from scenarios C, E, and F; scenario C significantly different from scenarios E and F; scenario D significantly different from scenarios A, E, and F (all P < .001). Discuss genetic evaluation: all scenarios significantly different from each other except scenarios A and F, and B and C (all P < .001). Discuss tamoxifen: all scenarios significantly different from each other except scenarios C and D, and E and F (all P < .001). Discuss surgery: all scenarios significantly different from each other except scenarios A and E, A and F, C and D, and E and F (all P < .001). Refer to a specialist: all scenarios significantly different from each other except scenarios A and B, A and F, and B and F (all P < .001).