Clinical Review
Get smart about dense breasts
An expert radiologist and dense breast educators address specific questions that will arise in your counseling and care of women who are...
When the American Cancer Society (ACS) updated its guidelines for screening mammography earlier this week,1 the effect was that of a stone being tossed into a tranquil pond, generating ripples in all directions.
The new guidelines focus on women at average risk for breast cancer (TABLE 1) and were updated for the first time since 2003, based on new evidence, a new emphasis on eliminating as many screening harms as possible, and a goal of “supporting the interplay among values, preferences, informed decision making, and recommendations.”1 Earlier ACS guidelines recommended annual screening starting at age 40.
TABLE 1 What constitutes “average risk” of breast cancer?
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The new guidelines are graded according to the strength of the rec ommendation as being either “strong” or “qualified.” The ACS defines a “strong” recommendation as one that most individuals should follow. “Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator,” the guidelines note.1
A “qualified” recommendation indicates that “Clinicians should acknowledge that different choices will be appropriate for different patients and that clinicians must help each patient arrive at a management decision consistent with her or his values and preferences.”1
The recommendations are:
- Regular screening mammography should start at age 45 years (strong recommendation)
- Screening should be annual in women aged 45 to 54 years (qualified recommendation)
- Screening should shift to biennial intervals at age 55, unless the patient prefers to continue screening annually (qualified recommendation)
- Women who desire to initiate annual screening between the ages of 40 and 44 years should be accommodated (qualified recommendation)
- Screening mammography should continue as long as the woman is in good health and has a life expectancy of at least 10 years (qualified recommendation)
- Clinical breast examination (CBE) is not recommended at any age (qualified recommendation).1
ACOG weighs in
Shortly after publication of the new ACS guidelines, the American College of Obstetricians and Gynecologists (ACOG) issued a formal statement in response2:
ACOG maintains its current advice that women starting at age 40 continue mammography screening every year and recommends a clinical breast exam. ACOG recommendations differ from the American Cancer Society’s because of different interpretations of data and the weight assigned to the harms versus the benefits….
ACOG strongly supports shared decision making between doctor and patient, and in the case of screening for breast cancer, it is essential. 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 examination.
Response of the USPSTF
The US Preventive Services Task Force (USPSTF) also issued a statement in response to the new ACS guidelines:
We compliment the American Cancer Society on use of an evidence-based approach to updating its mammography screening guidelines, and we plan to examine the evidence that the ACS developed and reviewed as we finalize our own recommendations on mammography. Women deserve the best information and guidance on screening mammography so that they can make the best choice for themselves, together with their doctor.
There are many similarities between our draft recommendation and the new ACS guidelines. Importantly, both identify strategies that help women, together with their doctors, identify and treat this serious disease. We both found that the benefit of mammography increases with age, with women in their 50s, 60s, and early 70s benefiting most from regular mammography screening. The USPSTF’s draft recommendations and the new ACS guidelines both recognize that a mammogram is a good test, but not a perfect one, and that there are health benefits to beginning mammography screening for women in their 40s.
We are hopeful that our recommendations and the ACS guidelines will facilitate dialogue between women and their clinicians, and lead to additional research into the benefits and harms of breast cancer screening.3
The USPSTF currently recommends biennial screening beginning at age 50.
A leader in breast health cites pros and cons of ACS recommendations
Mark Pearlman, MD, professor of obstetrics and gynecology at the University of Michigan health system, is a nationally recognized expert on breast cancer screening. He sits on the National Comprehensive Cancer Network (NCCN) breast cancer screening and diagnosis group, helped author ACOG guidelines on mammography screening, and serves as a Contributing Editor to OBG Management.
