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Scrutinizing screening: a critical interpretive review of primary care provider perspectives on mammography decision-making with average-risk women

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      A decision to undertake screening for breast cancer often takes place within the primary care setting, but current controversies such as overdiagnosis and inconsistent screening recommendations based on evolving evidence render this a challenging process, particularly for average-risk women. Given the responsibility of primary care providers in counseling women in this decision-making process, it is important to understand their thoughts on these controversies and how they manage uncertainty in their practice.


      To review the perspectives and approaches of primary care providers regarding mammography decision-making with average-risk women.

      Design and methods

      This study is a critical interpretive review of peer-review literature that reports primary care provider perspectives on mammography screening decision-making. Ovid MEDLINE®, Ovid PsycInfo, and Scopus databases were searched with dates from 2002 to 2017 using search terms related to mammography screening, uncertainty, counseling, decision-making, and primary health care providers.


      Nine articles were included following a review process involving the three authors. Using an inductive and iterative approach, data were grouped into four thematic categories: (1) perceptions on the effectiveness of screening, screening initiation age, and screening frequency; (2) factors guiding primary care providers in the screening decision-making process, including both provider and patient-related factors, (3) uncertainty faced by primary care providers regarding guidelines and screening discussions with their patients; and (4) informed decision-making with average-risk women, including factors that facilitate and hinder this process.


      The discussion of results addresses several factors about the diversity of perspectives and practices of physicians counseling average-risk women regarding breast cancer screening. This has implications for the challenge of understanding and explaining evidence, what should be shared with average-risk women considering screening, the forms of knowledge that physicians value to guide screening decision-making, and the consent process for population-based screening initiatives. Within the data, there was little attention placed on how physicians coped with uncertainty in practice. Given the dual responsibility of physicians in caring for both individuals and the larger population, further research should probe more deeply into how they balance their duties to individual patients with those to the larger population they serve.

      Related collections

      Most cited references 39

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      Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement.

      Update of the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for breast cancer in the general population. The USPSTF examined the evidence on the efficacy of 5 screening modalities in reducing mortality from breast cancer: film mammography, clinical breast examination, breast self-examination, digital mammography, and magnetic resonance imaging in order to update the 2002 recommendation. To accomplish this update, the USPSTF commissioned 2 studies: 1) a targeted systematic evidence review of 6 selected questions relating to benefits and harms of screening, and 2) a decision analysis that used population modeling techniques to compare the expected health outcomes and resource requirements of starting and ending mammography screening at different ages and using annual versus biennial screening intervals. The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient's values regarding specific benefits and harms. (Grade C recommendation) The USPSTF recommends biennial screening mammography for women between the ages of 50 and 74 years. (Grade B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women 40 years or older. (I statement) The USPSTF recommends against clinicians teaching women how to perform breast self-examination. (Grade D recommendation) The USPSTF concludes that the current evidence is insufficient to assess additional benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities for breast cancer. (I statement).
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        An integrative model of shared decision making in medical encounters.

        Given the fluidity with which the term shared decision making (SDM) is used in teaching, assessment and research, we conducted a focused and systematic review of articles that specifically address SDM to determine the range of conceptual definitions. In April 2005, we ran a Pubmed (Medline) search to identify articles published through 31 December 2003 with the words shared decision making in the title or abstract. The search yielded 681 citations, 342 of which were about SDM in the context of physician-patient encounters and published in English. We read and reviewed the full text of all 342 articles, and got any non-redundant references to SDM, which yielded an additional 76 articles. Of the 418 articles examined, 161 (38.5%) had a conceptual definition of SDM. We identified 31 separate concepts used to explicate SDM, but only "patient values/preferences" (67.1%) and "options" (50.9%) appeared in more than half the 161 definitions. Relatively few articles explicitly recognized and integrated previous work. Our review reveals that there is no shared definition of SDM. We propose a definition that integrates the extant literature base and outlines essential elements that must be present for patients and providers to engage in the process of SDM. The integrative definition of SDM is intended to provide a useful foundation for describing and operationalizing SDM in further research.
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          Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society.

          Breast cancer is a leading cause of premature mortality among US women. Early detection has been shown to be associated with reduced breast cancer morbidity and mortality.

            Author and article information

            [1 ]ISNI 0000 0004 1936 8649, GRID grid.14709.3b, Department of Family Medicine, , McGill University, ; 5858, chemin de la Côte-des-Neiges, Suite 300, Canada, QC H3S 1Z1 Canada
            [2 ]ISNI 0000 0004 1936 8649, GRID grid.14709.3b, Biomedical Ethics Unit, , McGill University, ; 3647 Peel St, Room 305, Montreal, QC H3A 1X1 Canada
            Public Health Rev
            Public Health Rev
            Public Health Reviews
            BioMed Central (London )
            23 April 2018
            23 April 2018
            : 39
            5978996 92 10.1186/s40985-018-0092-9
            © The Author(s). 2018

            Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

            Funded by: Quebec Breast Cancer Foundation
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