EXECUTIVE SUMMARY
The U.S. Preventive Services Task Force has issued new guidance on breast cancer screening and called for mammography every two years for women ages 50-74. For women ages 40-49, the guidance calls for informed, individualized decision-making based on a woman’s values, preferences, and health history.
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The recommendations apply to women age 40 and older who do not show any signs or symptoms of breast cancer, have not been previously diagnosed with breast cancer or a high-risk breast lesion, and who are not at high risk for breast cancer.
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There Is Insufficient Evidence To Assess The Benefit/risk Balance For Women Identified To Have Dense Breasts On An Otherwise Negative Screening Mammogram In Using Such Adjunctive Screening Methods As Breast Ultrasonography, Magnetic Resonance Imaging, Or Digital Breast Tomosynthesis.
The U.S. Preventive Services Task Force has issued new guidance on breast cancer screening and called for mammography every two years for women ages 50-74. For women ages 40-49, the Task Force recommends informed, individualized decision-making based on a woman’s values, preferences, and health history.1
The guidance falls in line with the Task Force’s 2009 recommendation that biennial mammography screening in average-risk women begin at age 50.2
The new recommendations allow women in their 40s to make an informed decision on mammogram screening. How should providers approach discussing mammograms with women this age, given the new guidance?
Breast cancer is uncommon among women in their 40s, notes Kirsten Bibbins-Domingo, PhD, MD, MAS, Task Force vice chair and professor of medicine, epidemiology, and biostatistics at the University of California, San Francisco. Mammography screening has the potential to reduce a woman’s chance of dying of breast cancer and also has potential harms such as false-positive test results and overdiagnosis that may lead to overtreatment, she notes. Providers should discuss the potential benefits, as well as the potential harms, says Bibbins-Domingo.
“A woman who values reducing her risk of dying from breast cancer, no matter how small the risk, and understands the potential harms may choose to begin screening at age 40,” states Bibbins-Domingo. “Other women may choose to begin later in the decade, or at age 50, when the likelihood of benefit is greater.”
UNDERSTAND THE GUIDANCE
The Task Force’s recommendations do not apply to all women. They apply only to women age 40 and older who do not show any signs or symptoms of breast cancer, have not been previously diagnosed with breast cancer or a high-risk breast lesion such as ductal carcinoma in situ (the most common type of noninvasive breast cancer), and who are not at high risk for breast cancer (have no known genetic mutation or a history of chest radiation at a young age). Women who are at high risk of breast cancer should consult their doctors for individualized recommendations regarding screening, the Task Force advises.
How about women with dense breasts? The Task Force concludes that there is insufficient evidence to assess the benefit/risk balance for women identified to have dense breasts on an otherwise negative screening mammogram in using such adjunctive screening methods as breast ultrasonography, magnetic resonance imaging, or digital breast tomosynthesis.1
As for women age 75 or older, the new guidance again finds insufficient evidence to assess the benefit/risk balance of continued screening mammography. The Task Force also concluded that current information is insufficient to assess the benefits and harms of adding tomosynthesis to conventional screening mammography.
The American College of Obstetricians and Gynecologists (ACOG) continues to stand by its breast cancer screening recommendations, which provide for annual mammograms beginning at age 40. It reiterated its stance in 2015 when the American Cancer Society revised its 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 55.3 (Contraceptive Technology Update reported on the Cancer Society’s guidance. See “American Cancer Society’s shift adds to confusion on breast cancer screening,” January 2016, which can be accessed at http://bit.ly/21eF4UL.)
Mark DeFrancesco, MD, MBA, ACOG president, in a statement in response to the Task Force’s guidance, states, “ACOG strongly supports shared decision-making between doctor and patient, and in the case of screening for breast cancer, it is essential. Given the differences among current organizational recommendations on breast cancer screening, we recognize that there may be confusion among women about when they should begin screening for breast cancer.”
ACOG is encouraging women to discuss screening with their providers, including concerns such as family history of cancer, risk factors, and their own personal experiences with breast cancer. The group also is advising clinicians to counsel women about the potential consequences of mammography, including false positive readings.
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, says that while he plans to continue recommending screening based on the Task Force’s guidance, he also will continue to support the preferences of his patients who prefer to initiate screening before age 50, to undergo annual screening, and to continue screening after age 74.
REFERENCES
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Siu AL; U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2016; doi: 10.7326/M15-2886.
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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.
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American College of Obstetricians and Gynecologists. ACOG statement on revised American Cancer Society recommendations on breast cancer screening. Accessed at http://bit.ly/1LBdBDf.
