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- Michelle Specht, MD
Advising patients about what age to start screening mammograms, or how to follow up when an imaging result is negative. What about dense breasts? Genetic testing? Modern breast care—especially diagnosing cancer—is fraught for primary care physicians. But this year they get a little extra help. Specialists in the Harvard system updated the CRICO Breast Care Management Algorithm in early 2019. And it takes into account some of the newest areas of clinical and legal risk. Our guest today is going to see us through some of the highlights of the updated breast care guideline.
Q.) Joining us now is Dr. Michelle Specht. Dr. Specht is an Assistant Professor of Surgery at Massachusetts General Hospital in Boston. She was on the CRICO Breast Care Algorithm Task Force. Dr. Specht, thank you for joining us.
A.) Thank you for having me, Tom.
Q.) Where are the big challenges for primary care providers today in breast care and how does the algorithm help?
A.) I think that one of the biggest challenges is that the treatment of breast cancer and recommendations for screening for breast cancer is a moving target. And kind of staying on top of the new algorithm and staying on top of the new recommendations can be a challenge in terms of managing a primary care practice when there is a lot of other disease processes that they have to keep an eye on. And so we sought to create this algorithm in a multi-disciplinary team approach to help keep our patients safe, and also allow PCPs and gynecologists to be able to have the latest information with regards to treating, and consolidated amongst all this different data.
Q.) This initiative was coming through CRICO, which is the malpractice insurance and patient safety company for Harvard, so what were the kinds of things that we were seeing in our claims?
A.) So I think that, you know, one of the things that we looked at in terms of reflecting upon the risk management, the claims that we’re seeing, is that communication between the primary care doc or the gynecologist managing breast care of patients is key. And so in stepping back and looking at ways that we can improve, it’s really interpreting the tests, making sure you’re reading the results, the mammogram, the ultrasound of the breast, communicating those results to the patient, and allowing the patient to understand that you followed up with the plan and followed up with the patient’s complaints if there is one to completion. And so that was one of the key take-home messages. Assessment, of course, is also key and that is going to happen with any assessment, but it’s really referring the patient to the correct physician, referring them to genetic counsellors when appropriate. That’s the way for primary care doctors to keep themselves safe.
Q.) When we look at our malpractice data, we’re seeing claims around dense breasts, conversations around the testing around that, low age, high-risk conversations, as well as negative test results. A lot of it seems around conversations.
A.) That’s correct. In my world taking care of breast cancer patients there’s a lot of conversations. It is a world where many of the decisions that we make around ordering tests or performing procedures, it’s a shared decision between the physician and the patient. But I think that if there is a self-detected mass by a patient, that’s something that primary care doctors really need to pay attention to. And even if the primary care doctor may feel as though the mass is not easily palpable, ordering tests to just be sure that there is not an abnormality there, is a good approach.
The other way to keep people safe is paying attention to family history. So much of our world is now talking about genetic testing and trying to identify patients who may be at higher risk for breast cancer, and so being sure to take a very thorough family history and referring to the appropriate genetic counselors as appropriate. Density, as you have already brought up, is a hot, hot topic. We know that there’s legislation that’s been passed in many states around the country that radiologists are required to report a patient’s breast density so that patients would have the option to add additional imaging if appropriate, and this is required by law in Massachusetts. This is something that appears on a women’s report of their mammogram that they receive, and so many primary care doctors and gynecologists may be having these questions about breast density. And we use the opportunity of this algorithm to help educate these physicians with regard to that.
Q.) The Harvard institutions have gotten together and created an algorithm, and they did that for the first time I think back in the 90’s with multiple updates since then. Is there something about the current moment that we thought we needed to update the algorithm again?
A.) This is something we do on a regular basis, and so I’ve had the opportunity to be part of the planning committee for this algorithm for many years, and I think I’ve participated in at least three, maybe four updates. And so there wasn’t anything particular that came about, but we kept some things the same and there are other things that we did change. So it was an appropriate time to do it.
Q.) I was going to ask you if you could spotlight a couple of key changes.
A.) So some of them we already alluded to before, but we really spent a lot of time this go around talking about breast cancer assessments and reviewing guidelines for those patients who present who are asymptomatic. We specifically began with taking the family history again. So much of our world is genetically based. We’ve learned more about genetics that that is key because I could imagine that if a patient were to develop breast cancer in the future and not taking a family history appropriately, there could be some risk associated to a PCP if they were not engaged in that genetic process early on. And so we emphasized the importance of updating the patient’s personal and family history of breast cancer. Reviewing the recommendations for genetic testing was another thing that we thought was important and advising those patients appropriately. And then other risk factors, whether they’ve had a biopsy that shows atypical cells in the past. Some patients who undergo radiation before the age of 30 may be of higher risk of getting breast cancer, and there are other reproductive risk factors.
Then we try to drill down and focus on the models. This is something that is part of the primary care and gynecologist’s practice on a routine basis now to utilize some on-line tools that assess a woman’s lifetime risk of developing a breast cancer. We do that because there are recommendations that if the lifetime risk of developing a breast cancer is greater than 20 percent, then one would consider adding additional screening to mammography. And that additional screening is normally a breast MRI. So that was something that we spent a lot of time talking about, those patients. Who needs routine screening? Who would need enhanced screening mammography?
We also incorporated multiple different recommendations. For previous algorithms, we were somewhat focused on organizations like the National Cancer Network and PCN, the American Cancer Society and their guidelines, but we tried to incorporate some of the guidelines that came out of the U.S. Health and Preventative Services to, you know, incorporate a lot of what the PCP’s are saying, which is not everyone needs a mammogram on a yearly basis but incorporate some of those recommendations.
The information with regards to how to deal with symptomatic patients, it was not that different than previous. Those were fairly similar to prior algorithms.
Q.) Would you say it is fair to say that the breast care algorithm helps clinicians manage both the clinical risk and their liability risk in breast care or is that distinction just not that useful?
A.) No, I think that’s extraordinarily useful. I think fundamentally one of the reasons I really enjoyed working with CRICO is, you know, clinical care is right there with minimizing risk. And so I think the two go really hand in hand, and so this is an algorithm that should be used for clinical practice. And if it’s used, I think, because I was part of designing it for clinical practice, then that’s also going to minimize risk.
Q.) If you had to say there is a meta message in the publishing of this update, what would you say that message is?
A.) I do think the meta message is communication. I think we are living in a world where the electronic medical record is extraordinarily helpful, but it also is something that we need to be wary of, to confirm that we continue to communicate with patients in a way that they understand and accept. So really the take-home message is we emphasize that if a patient is unsatisfied with the idea that there is nothing there, that they don’t see anything on imaging, you don’t seem to think that this is a problem: make sure that documentation of these interactions occurs in order to support those decisions. I think that, again, making sure that you see the mammogram and ultrasound report and confirm that there is negative imaging or if there is not, communicate with the radiologist or refer to a specialist, refer to a breast center, refer to a breast surgeon, because I think that’s going to keep everyone safe. Explaining to the patient the test results are very important, and that communication could be done by telephone. But make sure that she documents that telephone call similar to the way you would document a face-to-face encounter as well. And then make sure that these notifications of test results have a tracking system and that minimizing loss to follow up I think is very important.
Q.) Thank you so much, Dr. Specht.
A .) You’re welcome, thank you so much.
Q.) Dr. Specht is an Assistant Professor of Surgery at Massachusetts General Hospital in Boston. She was on the CRICO Breast Care Algorithm Task Force. I’m Tom Augello.
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