Multiple clinical practice guidelines for breast and cervical cancer screening: perceptions of US primary care physicians

Abstract

Background: Multiple clinical practice guidelines exist for breast and cervical cancer screening, and differ in aggressiveness with respect to the recommended frequency and target populations for screening.

Objectives: To determine (1) US primary care physicians' (PCPs) perceptions of the influence of different clinical practice guidelines; (2) the relationship between the number, aggressiveness, and agreement of influential guidelines and the aggressiveness of physicians' screening recommendations; and (3) factors associated with guideline perceptions.

Research design and methods: A nationally representative sample of 1212 PCPs was surveyed in 2006-2007. Cross-sectional analyses examined physicians' perceptions of the influence of different breast and cervical cancer screening guidelines, the relationship of guideline perceptions to screening recommendations in response to hypothetical vignettes, and the predictors of guideline perceptions.

Results: American Cancer Society and American College of Obstetricians and Gynecologists guidelines were perceived as more influential than other guidelines. Most physicians (62%) valued multiple guidelines, and conflicting and aggressive rather than conservative guideline combinations. The number, aggressiveness, and agreement of influential guidelines were associated with the aggressiveness of screening recommendations (P < 0.01)-which was highest for physicians valuing multiple-aggressive, lowest for physicians valuing multiple-conservative, and intermediate for physicians valuing multiple-conflicting, single, and no guidelines. Obstetrician/gynecologists specialty predicted valuation of aggressive guidelines (P < 0.001).

Conclusions: PCPs' perceptions of cancer screening guidelines vary, relate to screening recommendations in logically-consistent ways, and are predicted by specialty and other factors. The number, aggressiveness, and agreement of valued guidelines are associated with screening recommendations, suggesting that guideline multiplicity is an important problem in clinical decision-making.

FIGURE 1

Proportion of physicians rating individual breast and cervical cancer screening guidelines as very influential, by physician specialty (2006–2007 National Primary Care Physician Cancer Screening Survey). Bars represent the proportion of physicians of a given specialty group rating CPGs as a very influential. Total N = 1212 for breast cancer screening group, 1115 for cervical cancer screening group. Within-specialty differences in perceived influence of different clinical practice guidelines significant at P < 0.0001, for both breast and cervical cancer screening. USPSTF indicates US Preventive Service Task Force; ACP, American College of Physicians; AAFP, American Academy of Family Physicians; ACS, American Cancer Society; ACOG, American College of Obstetrics and Gynecology; FP, family practice/general practice; IM, internal medicine; OG, obstetrics/gynecology; All, all physicians combined.

FIGURE 2

Classification of primary care physicians according to breast and cervical cancer screening guideline(s) perceived as very influential (2006–2007 National Primary Care Physician Cancer Screening Survey). *Each box displays the proportion of physicians who perceived the designated guidelines or guideline combination as very influential. Separate percentages are displayed for physicians in the breast cancer (N = 1212) and cervical cancer (N = 1115) groups. ^†Multiple-conservative group included any of the following guideline combinations: USPSTF + ACP, USPSTF + AAFP, ACP + AAFP, USPSTF + ACP + AAFP. ^‡Multiple-conflicting group included any of the following guideline combinations: USPSTF + ACS, USPSTF + ACOG, ACP + ACS, ACP + ACOG, AAFP + ACS, AAFP + ACOG, ≥3 guidelines (not including USPSTF + ACP + AAFP). ^§Multiple-aggressive group consisted of ACS + ACOG. USPSTF indicates US Preventive Service Task Force; ACP, American College of Physicians; AAFP, American Academy of Family Physicians; ACS, American Cancer Society; ACOG, American College of Obstetrics and Gynecology.

FIGURE 3

Cancer screening aggressiveness scores of primary care physicians in different guideline perception groups (2006–2007 National Primary Care Physician Cancer Screening Survey). Model-adjusted means, representing predicted marginals from general linear model of cancer screening aggressiveness, controlling for physician and practice characteristics. A 10-point difference in aggressiveness score represents 1 standard deviation. Total N = 1212 for breast cancer screening group, 1115 for cervical cancer screening group. Multiple-conservative group included any of the following guideline combinations: USPSTF + ACP, USPSTF + AAFP, ACP + AAFP, USPSTF + ACP + AAFP. Multiple-conflicting group included any of the following guideline combinations: USPSTF + ACS, USPSTF + ACOG, ACP + ACS, ACP + ACOG, AAFP + ACS, AAFP + ACOG, ≥3 guidelines (not including USPSTF + ACP + AAFP). Multiple-aggressive group consisted of ACS + ACOG. CI indicates confidence interval; USPSTF, US Preventive Service Task Force; ACP, American College of Physicians; AAFP, American Academy of Family Physicians; ACS, American Cancer Society; ACOG, American College of Obstetrics and Gynecology.