Will improving breast cancer risk assessment with AI lead to better outcomes?

The U.S. Preventive Services Task Force recommends that clinicians offer risk-reducing medications to women who are at increased risk of breast cancer and at low risk for adverse medication effects. However, clinical tools used to estimate risk of breast cancer, such as the Breast Cancer Risk Assessment Tool​ and the Tyler-Cuzick Risk Model​, perform only modestly better than random chance, with lower performance in African American and Hispanic women​. The limitations of these tools have stimulated the development of artificial intelligence (AI) models that analyze patterns in screening mammography images​ to more accurately predict breast cancer risk in all populations.

A 2023 systematic review​ of 16 studies found that the median area under the receiver operating characteristic curve (AUC) for AI imaging tools was 0.72, compared to 0.61 for breast density or clinical risk factor-based tools. Of note, in 7 of 8 studies that compared AI risk prediction to assessments that combined AI with clinical risk factors, the latter did not produce more accurate risk estimates than AI alone.

In a later study​ of an AI model that utilized retrospective data from more than 300,000 patients aged 50 to 70 years who had screening mammograms in the United Kingdom, the overall AUC was 0.7, with no differences in performance across ethnic or age groups. Similarly, in a recent U.S. study​, a deep learning model involving mammograms from more than 67,000 patients produced an AUC of 0.71, compared to an AUC of 0.53 for breast density.

Last year, the U.S. Food and Drug Administration approved an AI test that analyzes a single screening mammogram performed within the past 12 months to classify patients as at average (less than 1.7%), intermediate (1.7% to 3%), or high (greater than 3%) risk of developing breast cancer over the next 5 years. Everlywell, a digital health company, is charging $249 for this test​, which does not require a doctor’s order and is not covered by insurance. Patients are directed to share their report with their primary care clinicians to discuss next steps, which for those at intermediate or high risk could include more intensive screening or risk-reducing medications.

The trouble is, we don’t know if more accurate cancer risk prediction improves patient-oriented outcomes. Previous trials of risk-reducing medications such as tamoxifen and raloxifene used eligibility thresholds based on clinical risk assessments and showed reductions in breast cancer diagnoses, but not breast cancer deaths. Lifestyle modifications such as increasing physical activity, healthy eating patterns, and limiting alcohol consumption also reduce breast cancer risk, but whether women with increased risk will be more motivated to adopt these behaviors is unclear. In the absence of such evidence, AI tools may only increase preventive care costs without producing health benefits.

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This post first appeared on the AFP Community Blog.

Time, access, and continuity: unleashing the power of primary care

In a recent editorial coauthored with the editors of six other US family medicine journals, Dr. Sumi Sexton, American Family Physician’s editor-in-chief, highlighted the established benefits of having continuous primary care. These include higher screening rates, fewer emergency department visits and hospitalizations, and lower costs of care for patients with chronic diseases. A 2020 systematic review found that better primary care continuity is associated with lower all-cause mortality. A retrospective cohort study​ of more than 100,000 adults in 48 Dutch general practices suggested that the benefits of continuity increase with longer duration: people registered with the same practice for greater than 5 years had lower odds of urgent hospital admission and lower hospital costs.

How does continuous primary care achieve positive impacts on health? Dr. Sexton and colleagues wrote:

The beneficial impact of primary care on population health likely reflects the core functions of primary care, including continuous relationships, whole-person care, better access, better quality, a greater focus on prevention, more appropriate and cost-effective testing, and early management of medical issues. Yet there is little emphasis on these core principles and continuous care in the quality measures to evaluate health care.

Paying primary care physicians based on value rather than volume of services, also known as value-based payment (VBP), is intended to promote wellness and improved health outcomes. However, Dr. Jeffrey Millstein observed in a commentary in the Journal of General Internal Medicine​ that misaligned VBP incentives sabotage effective primary care by reducing appointment access, impairing healing relationships, and discouraging medical students and advanced practice providers from choosing primary care careers:

What does the VBP-influenced primary care workday look like? It begins with a schedule overcrowded with perfunctory wellness visits that require excessive documentation. Visits that satisfy metrics crowd out access for patients with more acute symptoms or other concerns that cannot wait for weeks or months. … Diagnosis code suggestion pop-up alerts are now a constant distraction. … Capturing illness severity matters, but the current state is eroding PCPs’ ability to focus on the concerns patients bring to the exam room.

Access for patients is important, but so are sustainable clinician workloads. Medicare billing data suggest that family physicians require an average total time of 26 minutes per office visit, including non–face-to-face work. Based on this figure, Dr. Clark Trapp estimated in an FPM article that a sustainable workload for a full-time clinician is 20 patient visits per day and a panel size of 1,354, considerably lower than the current average of 1,727. Evidence demonstrates that reduced visit time pressure is associated with more comprehensive care​, particularly for patients with three or more chronic conditions. In contrast, primary care physicians with overloaded schedules who chronically experience “time scarcity”​ report disillusionment and dissatisfaction and cope by ordering unneeded testing, placing unnecessary referrals, and triaging sick patients to urgent care and the emergency department rather than seeing them in the office.

Sufficient time, access, and continuity are essential to unleashing the power of primary care to improve and maintain good health. Missing any of these elements greatly diminishes that power.

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This post first appeared on the AFP Community Blog.

The breadth of family medicine in one meeting

My wife and I returned last night from the annual Family Medicine Education Consortium meeting, which was held in Atlantic City this year. Despite the rainy weather, it was an enjoyable conference. I presented the latest evidence on multicancer blood tests, which are limited and imperfect tools that family doctors should think twice about ordering for their patients even if Galleri is approved by the U.S. Food and Drug Administration. Plenary speakers included family physician and YouTube sensation Mike Varshavski, DO, better known as Doctor Mike. Over two packed days, I was only able to sample a small slice of the 400+ presentations (including posters) by Northeast family medicine faculty, residents, and medical students. Nonetheless, these demonstrate the tremendous clinical and policy breadth of the specialty of family medicine. To show that breadth, and for the curious who want to know what sorts of talks I gravitate to at a conference like this, here are the topics of the oral presentations I attended:

Shaping the future of size-inclusive care: lessons from a medical student elective

Continuous glucose monitor utilization for insulin-dependent patients in family medicine clinic

A mixed-methods evaluation of Pennsylvania IMPLICIT Network sites

A 40-year retrospective cohort study of primary care alumni of NEOMED

Beyond statins

The Pap stops here: cervical cancer screening for women with HIV

From PCE to PREVENT: rethinking CVD risk in family medicine

This is our lane: building confidence in firearm storage safety conversations with patients

Primary care for all Americans: the current evidence and the plan to fix

Joint hypermobility in family medicine

An integrative approach to metabolic syndrome

Enhancing your research workflow with artificial intelligence

Shaping the future of care: where leadership, policy, and AI converge

When ideology dictates science policy: Trofim Lysenko and Robert F. Kennedy, Jr.

30 years ago, I took a college class on the history of Russian and Soviet science. One of the more infamous figures in an otherwise accomplished pantheon of scientists was a man named Trofim Lysenko, who rejected Mendelian genetics and espoused a form of agricultural pseudoscience. In a naturally self-correcting scientific system, he should have been an historical footnote, but by cleverly aligning his theories with Marxist ideology and ingratiating himself with Joseph Stalin, he managed to hold on to power for decades, at the expense of thousands of legitimate scientists and the Soviet people who depended on successful crop yields to feed their families.

Trofim Lysenko

Studying Lysenko, I would have been shocked if I had known that history would repeat itself in the United States, where a similar figure would promote thoroughly debunked theories about childhood vaccines and elevate his ideology above science at every turn. Thanks to elections and Presidential term limits, Robert F. Kennedy Jr.'s reign as the head of the U.S. Department of Health and Human Services (HHS) is likely to be much shorter than Lysenko's in the Soviet Union. However, the damage he has done to our scientific institutions and the scourge of preventable infectious diseases he has unleashed may take many more years to be repaired.

Robert F. Kennedy, Jr.

I am not the first person to compare the HHS Secretary's actions to those of Lysenko, but I don't believe there is a more definitive treatment of this analogy than my perspective article in the Fall 2026 issue of the Journal of Lancaster General Hospital.

e-Cigarettes for tobacco smoking cessation

Although e-cigarettes are generally considered to be less harmful than combustible cigarettes, whether vaping should be explicitly incorporated into tobacco smoking cessation strategies is controversial. In 2021, the US Preventive Services Task Force (USPSTF) found insufficient evidence to determine the balance of benefits and harms of e-cigarettes for smoking cessation in adults. At that time, the USPSTF cited a lack of well-designed, randomized controlled trials (RCTs) that reported smoking abstinence and adverse events. Other concerns included potential effects of e-cigarette promotion on already high rates of e-cigarette initiation in children and adolescents.

Subsequent studies have supported the utility of e-cigarettes for smoking cessation. A Swiss RCT that compared e-cigarettes to usual care cessation strategies (counseling and medications) found that the e-cigarette group was more likely to be abstinent from tobacco at 6 months (number needed to treat [NNT] = 6-8); adverse events were similar between groups. A Cochrane review of 88 studies, including 47 RCTs, found high-certainty evidence that e-cigarettes increased smoking cessation at 6 months to 1 year compared to nicotine replacement therapy (NRT) and other smoking cessation treatments. e-Cigarettes were associated with a similar incidence of adverse events to NRT and more adverse events than counseling (number needed to harm [NNH] = 7). Serious adverse events were not increased in the e-cigarette groups. Another RCT in persons of low socioeconomic status found that vaping nicotine was more effective than NRT for achieving tobacco abstinence at 6 months (NNT = 5).

A working group of the international Society for Research on Nicotine and Tobacco recently published recommendations to US-based clinicians on integrating e-cigarettes into conversations with patients about the risks and benefits of pharmacologic treatments for smoking cessation. Notably, the group recommends that “patients should not be required to first try or fail an FDA-approved medication before using an e-cigarette for cessation because supporting cigarette cessation is the primary goal.” If a patient chooses e-cigarettes, they advise using products authorized for sale by the US Food and Drug Administration and counseling patients to completely substitute e-cigarettes for combustible cigarettes as quickly as possible.

Like combustible cigarettes, e-cigarettes appear to increase the risk of chronic respiratory conditions in adults. An FPIN Clinical Inquiry found several observational studies that associated e-cigarette use with asthma, chronic obstructive pulmonary disease (COPD), and asthma-COPD overlap syndrome. Nonetheless, the working group endorsed long-term e-cigarette use as a harm reduction strategy for maintaining complete abstinence from combustible cigarettes in patients who are unable to transition away from nicotine altogether.

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This post first appeared on the AFP Community Blog.

Discontinuing statins for primary prevention in older adults

The major randomized controlled trials (RCTs) that established the benefits of statins in preventing atherosclerotic cardiovascular disease (ASCVD) generally did not enroll persons older than 75 years. Once a patient who has been taking a statin for primary prevention reaches that age, are there additional benefits to continuing it, or conversely, are there harms associated with discontinuing? In 2020, a systematic review of international guidelines on cardiovascular disease prevention found “little specific guidance for physicians who are considering statin discontinuation in older adults in the context of declining health status and short life expectancy.”

A 2024 systematic review identified 35 observational studies and a single RCT comparing statin discontinuation to continuation. The observational studies showed that statin discontinuation in all age groups was associated with statistically significant increases in all-cause mortality (hazard ratio (HR) = 1.92), cardiovascular mortality (HR = 1.63), and cardiovascular events (HR = 1.31), with similar results in adults 75 years and older. The single RCT was performed in 381 older adults with deteriorating functional status and an estimated life expectancy of 1 month to 1 year. 60-day mortality was similar between the groups (23.8% with discontinuation vs 20.3% with continuation, p=0.36), and quality of life was better in the group no longer taking statins.

An expert panel recently utilized this limited evidence base to create a clinical practice guideline on deprescribing statins in older persons. A synopsis of the guideline is available in an algorithm. The guideline suggests deprescribing statins in older adults at end-of-life and continuing them for primary and secondary prevention in other adults older than 65. Several factors may prompt a conversation about statins: frailty, pill burden, functional limitations, cognitive impairment, complex care needs, and advanced illness (eg, cancer). Select patients with life expectancies greater than 1 year may reasonably decide to discontinue statins based on their personal goals and the value they assign to preventing future cardiovascular events.

The results of a pragmatic, open-label RCT published this month in The Lancet Healthy Longevity support individualized decision-making regarding statin continuation in older adults. 1,180 French adults 75 years and older who had been taking a stain for primary prevention for at least 1 year and had no evidence of dementia or another progressive life-limiting disease were randomly assigned to stop or continue taking statins. After 3 years, there were no statistical differences in all-cause mortality or cardiovascular events between the groups. However, the group that discontinued statins had no advantages in quality or life, cognitive function, functional status, symptom burden, or adverse events.

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This post first appeared on the AFP Community Blog.