American Cancer Society’s shift adds confusion on breast screening

The New Year might bring more changes when it comes to breast cancer screening recommendations. A January 2016 consensus conference, called by the American College of Obstetricians and Gynecologists (ACOG), will bring together major organizations and women’s healthcare providers to evaluate and interpret available data and to develop uniform national guidelines on breast cancer screening.

The conference comes on the heels of American Cancer Society’s (ACS) October 2015 recommendations that indicate that women should begin having yearly mammograms at age 45 and should change to having mammograms every other year beginning at age 55. The new guidance does not recommend clinical breast examination for breast cancer screening among average-risk women at any age.¹

A review of the evidence considered in making the recommendations was co-published in The Journal of the American Medical Association, along with the guidance.² (To help providers explain the new guidance, the Journal developed a handout that may be copied for patient use. Download it at http://bit.ly/1kmCNXc.)

“These recommendations are made with the intent of maximizing reductions in breast cancer mortality and years of life saved while being attentive to the need to minimize harms associated with screening,” said Kevin Oeffinger, MD, chair of the ACS breast cancer guideline panel and a family physician at Memorial Sloan Kettering Cancer Center in New York City, in a statement accompanying the guidance. “The benefits, burdens, and judgment about that balance differ depending on a woman’s age, health, values, and preferences. These recommendations recognize and reflect those differences.”

In the United States, an estimated 231,840 women will be diagnosed with breast cancer in 2015.³ The disease continues to rank second after lung cancer as a cause of cancer death in women in the United States, and it is a leading cause of premature mortality in women. Statistics show that in 2012, deaths from breast cancer accounted for 783,000 years of potential life lost and an average of 19 years of life lost per death.⁴ While progress has been made in decreasing mortality, estimates indicate 40,290 women in the United States will die of breast cancer in 2015.³

The ACS guidance, the first issued since 2003, looks at screening mammography for average-risk women, defined as those with none of the following: personal history of breast cancer, a confirmed or suspected mutation associated with elevated risk, or history of chest wall radiation at a young age. The ACS group classified recommendations as “strong” when the benefits of guidance recommendation adherence outweigh undesirable impacts, or “qualified” when “there is clear evidence of benefit of screening but less certainty about the balance of benefits and harms, or about patients’ values and preferences, which could lead to different decisions about screening.”¹

The new recommendations are as follows:

• Women with an average risk of breast cancer — most women — should begin yearly mammograms at age 45. (Strong)
• Women should have the opportunity to begin annual screening between the ages of 40 and 44. (Qualified)
• At age 55, women should have mammograms every other year, though women who want to continue yearly mammograms should be able to do so. (Qualified)
• Regular mammograms should continue for as long as a woman is in good health and has a life expectancy of 10 years or longer. (Qualified)
• The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age. (Qualified)

The American Cancer Society is encouraging women that the best way to know when to begin screening for mammograms and how often to get screenings is to talk to their medical providers. Women should initiate discussions about breast cancer screening with medical providers by age 40 and should share family history and personal medical history to determine whether they are at average risk or higher risk for breast cancer.⁵

“This guideline relies on the best evidence to offer new, more precise guidance taking into account a woman’s age, health, and personal values and preferences,” said Elizabeth “Terry” Fontham, founding Dean of the School of Public Health at Louisiana State University Health Sciences Center in New Orleans and chair of the ACS Guideline Development Group. “Though the evidence shows that there are some benefits from mammography screening starting at age 40, those benefits more clearly outweigh the harms from age 45 onward.”

Some women will choose to begin screening between age 40 and 44, because they are concerned about their risk of breast cancer, either in general or because they are at higher risk, and are less concerned about the chances of experiencing false positive findings, noted Fontham in a press statement. Those women should have the opportunity to start screening at 40 if they choose, she stated.

SEEKING CONSENSUS

In calling for the January 2016 consensus meeting, the American College of Obstetricians and Gynecologists (ACOG) noted its differences with the new ACS guidance and released a statement saying that it holds a “different interpretation of data and the weight assigned to the harms versus the benefits.”⁶

It maintains its current advice that women starting at age 40 continue mammography screening every year, and recommends a clinical breast exam ever year for women ages 19 and older.

“ACOG strongly supports shared decision-making between doctor and patient, and in the case of screening for breast cancer, it is essential,” reads the organization’s statement. “We recognize that guidelines and recommendations evolve as new evidence emerges, but currently ACOG continues to support routine mammograms beginning at 40 years as well as continued use of clinical breast examinations.”

In 2009, the US Preventive Services Task Force developed guidance that calls for women ages 50 to 74 to receive a screening mammogram every two years. For women younger than 50, some might choose to be screened based on individual risk factors, the guidance notes.⁷ The Task Force’s recommendation for fewer mammograms was based on its assessment that more frequent mammograms increase the risk of false positive studies, overdiagnosis, and overtreatment. The ACS guidance is based on its analysis of evidence indicating that more screenings are necessary to catch more tumors at an earlier stage.

The updated ACS guidelines should result in more women starting mammograms later in life, notes Andrew Kaunitz, MD, University of Florida Research Foundation professor and associate chairman of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine–Jacksonville. Because the guidance endorses biennial screening for many women, patients following ACS protocol will have fewer lifetime screens than with earlier recommendations, observes Kaunitz.

In performing fewer breast examinations during well woman visits, clinicians now will have more time for assessing family history and other risk factors for breast cancer, as well as for encouraging dialogue regarding screening recommendations, Kaunitz notes.

REFERENCES

1. Oeffinger KC, Fontham ET, Etzioni R, et al; American Cancer Society. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA 2015; 314(15):1599-1614.
2. Myers ER, Moorman P, Gierisch JM, et al. Benefits and harms of breast cancer screening: A systematic review. JAMA 2015; 314(15):1615-1634.
3. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA Cancer J Clin 2015; 65(1):5-29.
4. Howlander N, Noone A, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2012. Bethesda, MD: National Cancer Institute; 2015.
5. Simon S. American Cancer Society releases new guideline. Accessed at http://bit.ly/1PEeXlC.
6. American College of Obstetricians and Gynecologists. ACOG statement on revised American Cancer Society recommendations on breast cancer screening. Accessed at http://bit.ly/1LBdBDf.
7. Nelson HD, Tyne K, Naik A, et al; US Preventive Services Task Force. Screening for breast cancer: An update for the US Preventive Services Task Force. Ann Intern Med 2009; 151(10):727-737.