Using an individualized approach to decide whether asymptomatic women under age 50 should have mammograms is at the center of the final screening guidelines published by the US Preventive Services Task Force (USPSTF), but the group
Anees B. Chagpar, MD
Anees B. Chagpar, MD
Using an individualized approach to decide whether asymptomatic women under age 50 should have mammograms is at the center of the final screening guidelines published by the US Preventive Services Task Force (USPSTF), but the group’s final say on the matter is not likely to settle a matter which has been hotly debated for several years.
The recommendations, which do call for biennial testing for women aged 50 to 74 years, note that while “adequate evidence” suggests that mammography screening has reduced breast cancer mortality, most of the benefit for women at average risk for breast cancer is derived by those aged 50 to 74 years who undergo screening every 2 years.
The new guidelines were announced by the USPSTF and published simultaneously in the Annals of Internal Medicine,1 which also ran an editorial saying it was “time to douse the firestorm” concerning screening. Nevertheless, the immediate reaction in the oncology community suggested the debate would continue.
“Although for many years the dogma was that women should have mammograms ‘once a year for a lifetime’ starting at age 40 years, current evidence shows that the balance of risks and benefits of screening, particularly among women in their 40s, warrants more nuanced decision making,” Christine Laine, MD, MPH, the editor-in-chief of Annals of Internal Medicine, and colleagues wrote in an editorial accompanying the guidelines article, adding that “the potential benefits of preventing breast cancer deaths are real, but the likelihood of those benefits is small and no definitive evidence shows that screening reduces total mortality.”2
However, the American College of Radiology (ACR) and the Society of Breast Imaging (SBI) said in a joint statement that following the recommendations would result in lethal consequences for thousands of women each year.
“A recent study in the British Medical Journal confirms that early detection of breast cancer via mammography is critical for improving breast cancer survival, regardless of therapy advances. Moving away from yearly screening in women 40-and-older endangers women, would cause needless death and disfigurement of women, and would simply not be good breast cancer screening policy,” said Debra Monticciolo, MD, FACR, chair of the ACR, in the joint statement.
Murray Rebner, MD, immediate past president of SBI, called the USPSTF’s guidelines “scientifically and methodologically flawed.” He said the group continues to recommend that women begin annual screenings starting at age 40.
Screening Asymptomatic Women for Breast Cancer
Overall, the USPSTF guidelines apply to asymptomatic women who do not have preexisting breast cancer or a previously diagnosed high-risk lesion, or who are not at a higher risk level because of genetic mutations, a family history of the disease or a history of chest radiation at a young age.
The key recommendations, tailored to age levels, are these:
• 40-49 years: Recommends informed, individualized decision-making based on a woman’s values, preferences, and health history. (C recommendation)
• 50-74 years: Recommends mammography every 2 years. (B recommendation)
• 75 years and older: More research needed. Current science inadequate to recommend for or against. (I statement for insufficient evidence)
The US Department of Health and Human Services said the recommendations will not affect insurance coverage for mammography because of federal legislation signed in December 2015 that keeps benefits the same through 2017.
“Women 40 years and older enrolled in most health insurance plans will continue to be covered for screening mammography every 1 to 2 years without copays, coinsurance, or deductibles—just as they are today,” said Nancy C. Lee, MD, director, Office of Women’s Health at the US Department of Health and Human Services., in a statement. “If a woman is 40 years and older and her doctor determines that a mammogram is appropriate, she will not have to pay out of pocket.”
The debate over the recommendations would continue during the legislative protections, indicated William T. Thorwarth, Jr, MD, FACR, chief executive officer of the ACR. “This congressionally mandated delay will help providers continue to save tens of thousands of lives each year while the USPSTF recommendations and their creation process are vetted by breast cancer screening experts and lawmakers,” Thorwarth said in statement.
Mammography’s Benefits Increase With Age
In expanding upon the USPSTF findings, Albert L. Siu, MD, MSPH, who chaired the panel, noted that the American Cancer Society (ACS) also has recognized that the benefits of mammography increase with age.
In October 2015, the ACS updated its breast cancer screening guideline3 to recommend that women at an average risk of breast cancer should wait to undergo annual screening mammography until they reach the age of 45. Additionally, after the age of 55, the guideline recommends transitioning mammography to every other year. Prior ACS recommendations, which were formulated in 2003, recommended that annual screening should begin at age 40.
“We hope this growing convergence among distinct organizations gives women and their healthcare providers confidence in the science that supports mammography screening,” said Siu, who is the Ellen and Howard C. Katz Mount Sinai Health System chair and professor of the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai.
Despite the objections raised by some in the oncology community, others expressed support.
Anees B. Chagpar, MD, associate professor of Surgery (Oncology) and director of The Breast Center at Smilow Cancer Hospital at Yale-New Haven, said the new guidelines change the focus of screening.
“Women should know what their risk is,” Chagpar said in an interview with OncLive. “Women who are at high risk, for example, who have a genetic mutation that puts them at higher risk for developing breast cancer, and who have a very strong family history of breast cancer, should really be talking to their doctors on when they should be starting mammography, and whether they should be having other tests, as well.”
“If you look at national trends and ask women, ‘have you had a mammogram this year?’ A lot of women forget; therefore, if you get a mammogram every other year, that’s probably just fine,” Chagpar said. “It’s not sending the message—and I hope that it doesn’t send the message—that mammograms aren’t important. They still are. It’s the best technique for finding cancers early when they are the most treatable, and the advent of screening mammography has truly been critical in the reduction in mortality that we have seen over the last several decades.”
In creating the final version of the recommendations, the USPSTF conducted a review of the science since its 2009 recommendation. The draft recommendation was available for public comment from April 21 to May 18, 2015.
1. Siu AL on behalf of the US Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement [published online January 11, 2015]. Ann Intern Med. doi:10.7326/M15-2886.
2. Laine C, Dickersin K, Mulrow C. Time to douse the firestorm around breast cancer screening [published online January 11, 2015]. Ann Intern Med. doi:10.7326/M15-3065.
3. Oeffinger KC, Fontham ETH, Etzioni R, et al. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society. JAMA. 2015;314(15):1599-1614.