ACOG Revises Breast Cancer Screening Guidance: Ob-Gyns Promote Shared Decision Making

Washington, DC—Today, The American College of Obstetricians and Gynecologists (ACOG) released its updated breast cancer screening guidance for average-risk women. ACOG’s revised guidelines continue to underscore the importance of screening mammography and its role in early detection of breast cancer and consequent reduction in mortality. Among the changes, however, is an emphasis on patient–provider shared decision making to help women make informed, individualized decisions about when to start screening, the frequency of screening and when to end screening.

“Our new guidance considers each individual patient and her values,” said Christopher M. Zahn, M.D., ACOG Vice President of Practice Activities. “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.”

Shared Decision-Making

ACOG’s updated breast cancer screening guidance promotes a focus on patient autonomy and shared decision making to help women and their ob-gyns decide on an appropriate breast cancer screening strategy from among the range of reasonable options encompassed within published major guidelines. 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. This patient-centered, individualized approach empowers women to fully consider their breast cancer screening options and take an active and informed role in their health care.

Benefits and Harms of Screening

Breast cancer is the most commonly diagnosed cancer in women and the second leading cause of cancer death in American women. Regular screening mammography starting at age 40 years reduces breast cancer mortality in average-risk women. Screening, however, also exposes women to potential harms, such as callbacks, anxiety, false-positive results, overdiagnosis and overtreatment. Varying judgments about the appropriate balance of benefits and harms have led to differences among the major guidelines about what age to start, what age to stop and how frequently to recommend mammography screening in average-risk women. The variations between the current screening guidelines have created challenges for both patients and providers in choosing or recommending the most appropriate approach to screening in a particular patient.

Summary of ACOG’s Updated Recommendations for Screening Mammography

• Women at average risk of breast cancer should be offered screening mammography starting at age 40 years. If they have not initiated screening in their 40s, they should begin screening mammography by no later than age 50 years. The decision about the age to begin mammography screening should be made through a shared decision-making process. This discussion should include information about the potential benefits and harms.
• Women at average risk of breast cancer should have screening mammography every one or two years based on an informed, shared decision-making process that includes a discussion of the benefits and harms of annual and biennial screening and incorporates patient values and preferences.
• Women at average risk of breast cancer should continue screening mammography until at least 75 years. Beyond age 75 years, the decision to discontinue screening mammography should be based on a shared decision making process informed by the woman's health status and longevity.

For more information, including online shared decision-making tools and resources, please visit ACOG’s Breast Cancer Screening and Treatment Resource Overview.

The Practice Bulletin #179, “Breast Cancer Risk Assessment and Screening in Average-Risk Women,” is available in the July 2017 issue of Obstetrics & Gynecology.

Other recommendations issued in the July Obstetrics & Gynecology

Committee Opinion #705, “Mental Health Disorders in Adolescents”

Mental health disorders in adolescence are a significant problem, relatively common, and amenable to treatment or intervention. Obstetrician–gynecologists who see adolescent patients are highly likely to see adolescents and young women who have one or more mental health disorders. Some of these disorders may interfere with a patient’s ability to understand or articulate her health concerns and appropriately adhere to recommended treatment. Some disorders or their treatments will affect the hypothalamic–pituitary–gonadal axis, causing anovulatory cycles and various menstrual disturbances. Adolescents with psychiatric disorders may be taking psychopharmacologic agents that can cause menstrual dysfunction and galactorrhea. Adolescents with mental illness often engage in acting-out behavior or substance use, which increases their risk of unsafe sexual behavior that may result in pregnancy or sexually transmitted infections. Pregnant adolescents who take psychopharmacologic agents present a special challenge in balancing the potential risks of fetal harm with the risks of inadequate treatment. Whether providing preventive women’s health care or specific obstetric or gynecologic treatment, the obstetrician–gynecologist has the opportunity to reduce morbidity and mortality from mental health disorders in adolescents by early identification, appropriate and timely referral, and care coordination. Although mental health disorders should be managed by mental health care professionals or appropriately trained primary care providers, the obstetrician–gynecologist can assist by managing the gynecologic adverse effects of psychiatric medications and providing effective contraception and regular screening for sexually transmitted infections. This Committee Opinion will provide basic information about common adolescent mental health disorders, focusing on specific implications for gynecologic and obstetric practice.

Committee Opinion #706, “Sexual Health”

Sexuality involves a broad range of expressions of intimacy and is fundamental to self- identification, with strong cultural, biologic, and psychologic components. Obstetrician–gynecologists often are consulted by patients about sexual health and are in a unique position to open a dialogue on sexual health issues. Several obstacles to frank conversations with patients about sexual health exist, including a lack of adequate training and confidence in the topic, a perception that there are few treatment options, a lack of adequate clinical time to obtain a sexual history, patients’ reluctance to initiate the conversation, and the underestimation of the prevalence of sexual dysfunction. However, data on reproductive and sexual health morbidity suggest sexual health is an important health care issue. Each year, an estimated 45,000 new cases of human immunodeficiency virus (HIV) and approximately 20 million sexually transmitted infections occur, 3 million women experience unintended pregnancies, and 1 million women are sexually assaulted. Openly discussing sexual health has the potential to prevent these unnecessary sexual health-related outcomes. Clinical conversations should acknowledge the contributions of sexuality, relationships, and sexual behavior to overall health. Obstetrician–gynecologists can address sexual health issues across a lifespan with their patients and encourage a strategic foundation for women’s sexual health issues, resulting in improved public health overall. Obstetrician–gynecologists also can support policies that broaden the coalition for effective prevention of sexually transmitted infections and promote healthy sexuality, with the ultimate goal of improving health outcomes and public health.

Committee Opinion, #707, “Access to Emergency Contraception”

Emergency contraception refers to contraceptive methods used to prevent pregnancy in the first few days after unprotected intercourse, sexual assault, or contraceptive failure. Although the U.S. Food and Drug Administration approved the first dedicated product for emergency contraception in 1998, numerous barriers to emergency contraception remain. The purpose of this Committee Opinion is to examine barriers to the use of emergency contraception, emphasize the importance of increasing access, and review new methods of emergency contraception and limitations in efficacy in special populations.

Committee Opinion, #708, “Improving Awareness of and Screening for Health Risks Among Sex Workers”

The population of women who sell or exchange sex or intimate sexual services for material goods or services, also called “sex work,” often is unrecognized in the typical obstetric and gynecologic practice. The prevalence of this behavior among adult women is difficult to quantify because of its frequent omission from the routine sexual history by women and clinicians. Data on the prevalence of sex work in the United States are largely lacking. The American College of Obstetricians and Gynecologists supports increasing awareness about the health risks, preventive care needs, and limited health care services for female sex workers.

Practice Bulletin #190, Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. However, debate continues to surround the diagnosis and treatment of GDM despite several recent large-scale studies addressing these issues. The purposes of this document are the following: 1) provide a brief overview of the understanding of GDM, 2) review management guidelines that have been validated by appropriately conducted clinical research, and 3) identify gaps in current knowledge toward which future research can be directed.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org