MedicalResearch.com Interview with:
Jiyon Lee, M.D.
Assistant Professor of Radiology, NYU School of Medicine
NYU Cancer Institute, Breast Imaging Center
New York, New York 10016
Medical Research: What is the background for this study? What are the main findings?
Dr. Lee: Even before the USPSTF changed their breast screening guidelines in 2009, I conducted community outreach to help educate others on my area of expertise, breast imaging and breast screening. I presented lay friendly, illustrated, and practical explanations in a structured talk, about the big picture and the salient details, in a way that I would want if I were not a breast radiologist. As is customary for such community outreach, we solicited feedback from attendees. It was gratifying to hear the positive responses. That they wished for such education for others served as a clarion call that is understandable. Education should be objective and noncoercive. “Knowledge is power,” but only if complete and accurate.
Breast cancer is still a common disease, we are all at least at average risk, and screening is still standard of care. Much of the debate surrounding screening mammography centers on the age of onset of screening and the optimal screening interval. The USPSTF states that shared-decision making between women and their providers may occur, especially for women in 40-49 year group. But the TF does not stipulate when or how or by whom this talk will ensue, and notice that their guidelines refer to film mammography, and “biennial” mammography.
Since the time of this manuscript, the American Cancer Society issued new guidelines on 10/20/2015 that among its bullet points emphasized annual mammography for women 45-54 years and deemphasized clinical breast exam, while supporting option to start annually at age 40 with shared decision making to weigh what are referred to as “risks” and benefits. Although the fine print does reaffirm that annually starting at age 40 is the screening model that saves the most lives, the ACS is encouraging deliberate value judgment regarding “risks” and “harms.” Their fine print is also intimating that women 55 and over have nondense tissue and that their cancers are indolent. The ensued publicity and mixed messaging have caused another cycle of confusion regarding breast cancer screening. As the experts in this field of image-based screening, radiologists have opportunity to clarify and contextualize the issues and details of the screening discussion, and can do so with objectivity, respect for all sides of the debate, and compassion. All responsible ways to continually educate both women and all providers will enable both sides to engage in the discussion fairly. Because as we discourage paternalistic medicine and promote shared decision making, it’s not fair play if all responsible sides do not get fair say. Do realize that not all women see providers regularly, and depending on the medical subspeciality, not all providers are mentioning screening til women reach a certain age and may not relay importance of the physical exam components that complement imaging.
This article specifically highlights how such direct and interactive public education can effect potential benefit in two ways.
- First, directly reduce one of the core criticisms about screening: the “anxiety” that women may experience, which is heavily weighed as a “harm” of screening. Most women do not experience high anxiety, and are glad to have a test that may help them. And education can help demystify much of the process and protocol, and explain up to what may be that patient’s next test results if she engages in screening at all. No one can tell that.
- Two, education can directly increase one of the necessary components of shared decision making that is presumed in implementing breast screening: informing women. The pre- and post-lecture questionnaire, along with fact-based quiz questions, provided insight and enabled learning opportunity for the audience that are not usual for community outreach. Education that keeps on going—and is shareable!– after the lecture is done.
Medical Research: What should clinicians and patients take away from your report?
Dr. Lee: There are so many ways that we can all collaborate for the benefit of the women we serve. We are, after all, on the same side–the side of the patient. I present two quotations: this Japanese proverb “None of us is as smart as all of us.” and this lovely title I encountered on Pubmed “Evidence based medicine–how it relates to knowledge, wisdom, and serendipity.” (authors Van Andel, Fatovic-Ferencic, Holubar). Optimized usage of screening mammography is both simple and complex, and we can all agree is also in part defined by how you read the science, and whether you see the forest or the trees.
My direct public outreach aims to supplement and complement what women–not just those who are already patients–might hear and think they understand about the topic. I especially enjoy pairing up with other providers who will lecture on other topics. We can all learn in the experience, and the pairing can help place breast screening where I believe it belongs—on the shelf with other health and wellness initiatives, such as the prevention and early detection health aims.
Based on everything that breast imagers know because of our training and clinical experience, I am pro-screening. But higher and louder than that, I am pro-choice. Realize that screening is elective. I remind women that no one needs to get screened if she does not wish to, as long as it’s a conscious choice and not by default because of lack of access or awareness. In the USA, one of 8 women will get breast cancer in their lifetime, so that means 7 of 8 will not. So if a woman choses to never be screened, likely she will be okay with respect to breast cancer. Isn’t that wonderful? It’s just that we cannot tell exactly who will and who will not develop breast cancer, not down to each individual. So screening is a choice, and fortunately in our country, there are insurance and non-insurance ways to opt in. And they can change their mind along the way, which this country allows. But the choice should be informed, including information about the scientific rationale behind it, reasons for the apparent debate, and the process.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Lee: Continuing the dialogue and collaborative education with all women and providers–who are also potentially patients too! Shared decision making cannot happen if both sides do not have full and accurate information to share, and/or do not share. We can all help with that. My work is also exploring potential benefit of such educational efforts to other audiences. We cannot afford to assume anyone’s knowledge base on a topic still so wrought with mixed messaging. And in this wonderful country with its ethnic and cultural diversity, lack of awareness and lack of access can still undermine the work that all of us in medicine strive to do. Thank you for this interview opportunity
J Am Coll Radiol. 2015 Oct 17. pii: S1546-1440(15)00717-6. doi: 10.1016/j.jacr.2015.07.018. [Epub ahead of print]
Direct Interactive Public Education by Breast Radiologists About Screening Mammography: Impact on Anxiety and Empowerment.
Jiyon Lee, M.D. (2015). Breast Radiologist Discusses Screening Mammography Public Education