Getting to Goldilocks: ‘Just right’ breast screening

For Breast Cancer Awareness Month, Dr. Diana Buist tells how Group Health research helps women and their doctors decide if, when, and how to screen.

Every day, at least one woman at Group Health is diagnosed with breast cancer. It's the most frequently diagnosed cancer and the second most common cause of cancer death in U.S. women. That's why breast screening is a major research focus at Group Health Research Institute (GHRI), where we strive to be national and international leaders in the field. We're proud to be part of Group Health, which in the 1980s became the first health care organization to adopt risk-based, personalized breast cancer screening. We've always been ahead of the curve in putting research evidence into clinical practice. To stay ahead, we're using what we're learning about breast cancer to include women in conversations about if, when, and how they should be screened.

Over the decades, our understanding of breast cancer has evolved. Strong evidence now suggests that breast cancer is not one disease but has many subtypes. When it comes to breast cancer screening, treatment, and follow-up, one size does not fit all.

• Women have different risks for different breast cancer subtypes.
• Screening methods don't work equally well for all women or all cancer subtypes.
• And women respond differently to treatments and surveillance after therapy.

Controversy and passion

As we apply our new knowledge to improve breast cancer screening and post-treatment surveillance, we naturally provoke debate. You may remember the controversy in 2009 when the U.S. Preventive Services Task Force (USPSTF) changed recommendations about mammography for women in their 40s. People respond passionately to screening policy changes because so many of us have a personal experience with breast cancer. At GHRI, we think that passion is an asset.

We believe that women want to be involved in shared decision-making with their health care providers about breast cancer screening. And, in fact, the USPSTF now encourages women to talk with their doctors about a personalized screening plan. But for informed shared decision making to happen, women and their health care teams need unbiased information about the major benefit of screening: early cancer detection. They also need to know about potential harms, such as repeated radiation exposure and unneeded treatment. GHRI researchers help by providing evidence about both benefits and harms. Our goal is delivering solid research results that help women make reasoned, personalized, preference-based choices to screen or not to screen. Since many women want decision-making conversations to include information on insurance coverage and out-of-pocket costs, we advocate for transparency and evidence-based policies about screening coverage.

To achieve our goals, with our collaborators in the Breast Cancer Surveillance Consortium, we collect breast cancer screening information from community practices across the country. Women Group Health members who complete questionnaires during office visits and participate in studies are invaluable contributors to this work, which includes:

• determining which breast abnormalities are low vs. high risk, in collaboration with partners at Fred Hutchinson Cancer Research Center through the Early Detection Research Network;
• studying how age and chronic conditions influence when screening harms outweigh benefits;
• developing biostatistical methods for studying screening using observational data;
• participating in national networks such as CISNET and the Evidence-based Practice Centers;
• finding the best screening and surveillance technologies based on individual characteristics such as breast density; and
• optimizing care strategies for women diagnosed and treated for early stage breast cancer.

Can less care = more?

A growing trend in cancer screening is the rapid appearance of new methods. (A current example in the news and JAMA is low-dose CT lung screening.) We welcome industry innovations but need to remember that newer isn't always better and all technology must be evaluated for benefits in identifying early cancer vs. harms such as invasive biopsy of people without disease. To generate sound clinical guidelines about a new method, we need to know how many people need to be screened and exposed to potential harms to save a single life.

At GHRI, we seek information to help patients, providers, and policymakers find the Goldilocks point of cancer screening—not too much, nor too little. For breast cancer, we're helping women make their own screening decisions. We're assisting policymakers in optimizing guidelines to maximize community benefits and minimize harms. As we reflect on Breast Cancer Awareness Month, we're grateful for our research partners—Group Health members and providers and national collaborators—who work with us toward our goal of wise, effective, quality breast cancer screening for all women.

Diana S. Buist, PhD, MPH
Senior Investigator, Group Health Research Institute