Breast Screening Guideline Confusion

By JoAnn Pushkin

The recent spate of changes to national breast screening guidelines may have both patients and health providers scratching their heads. The main points of confusion are when screening should begin, how often a woman should be screened, and when screening should end.

The final United States Preventive Service Task Force (USPSTF) recommendations, issued in January 2016,¹ differed from current recommendations promulgated by several national health organizations and added to the conflicting advice. Since the USPSTF final guidelines were issued (suggesting screening begin at age 50 and repeat at a 2-year interval), both the American Cancer Society (ACS)² and the American Congress of Ob/Gyns (ACOG)³ have updated their own recommendations too.

In order to facilitate direct comparison of the guidelines, DenseBreast-info.org developed the Breast Cancer Screening Guideline Comparison (Table 1). As you can see, the ACS now recommends screening starting at age 45 with an option to start at 40, while ACOG recommends offering the screening starting at age 40 but not later than 50.

For mammography interval, the ACS suggests annually for ages 45-54 and every 1 or 2 years at age 55 and older, while ACOG suggests every 1 or 2 years without age qualifiers. The American College of Radiology and Society of Breast Imaging (ACR/SBI), American Medical Association, and National Comprehensive Cancer Network continue to recommend screening beginning at age 40 and continuing at an annual interval.

The age to stop mammography also differs among guidelines varying from a specific age cutoff (USPSTF states 74 years of age, ACOG suggests age 75 and then shared decision making), to stopping when life expectancy is less than 10 years (ACR/SBI and ACS).

Table 1: Breast Cancer Screening Guidelines – Comparison

Views on 3D mammograms (also known as tomosynthesis) differ, as well. ACR/SBI states that the technology is an “advance in breast imaging,” and the ACS and NCCN find it an “improvement” over 2D mammography in terms of detection and recall. USPSTF’s position is that there is “insufficient evidence to support routine use.” The ACOG and the AMA guidelines do not include a position.

With all of the different advice out there, it can be hard for providers to determine the most appropriate screening for their patients. DenseBreast-info.org believes that patients should start their screening mammograms before age 45 for the following reasons:

The entire reason we screen for breast cancer is to find it EARLY, when most treatable and survivable.
Breast cancer is the number one cause of death in women aged 35 to 54 years.⁴
Mammography has been proven to reduce deaths due to breast cancer in women screened beginning at age 40.²
Women at “high risk” for breast cancer due to known or suspected disease-causing mutation (such as BRCA1 or BRCA2) should begin screening at least by age 30, to include MRI. MRI is very sensitive and is recommended every year for women who are at high risk for breast cancer.

What about false positives?

About 10% of women having a screening mammogram will be called back for extra testing or views. This is normal. Among women called back, 95% do not have cancer. If a needle biopsy is necessary, even that is a simple test.
The newer technique of 3D mammography (tomosynthesis) is more able to show cancer AND results in fewer callbacks for extra testing.

What about screening in dense breasts?

Younger women are more likely to have dense breast tissue, which can hide cancer on mammography.
In women who have breasts categorized as “dense” (heterogeneously dense or extremely dense), adding screening ultrasound after a mammogram (2D or 3D) can help find more breast cancers. Because ultrasound detects more areas which need follow-up, there is more to check. Ultrasound does also increase the chance of needing a needle biopsy to determine if something detected is cancerous or not.

For more information on breast screening, risk factors, and dense breasts, visit DenseBreast-info.org.

References:

Siu AL, on behalf of the U.S. Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164:279-296. doi:10.7326/M15-2886.

Oeffinger KC, Fontham ET, Etzioni R, et al. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society. JAMA. 2015;314(15):1599-614. https://www.youtube.com/watch?v=6SKh6Tm2HZs&feature=youtu.be.

ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrcian-Gynecologists. Number 179. July 2017. https://www.acog.org/Resources-And-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Breast-Cancer-Risk-Assessment-and-Screening-in-Average-Risk-Women.
CDC Wonder. Multiple Cause of Death Data. https://wonder.cdc.gov/mcd.html. Page last reviewed December 8, 2016.

JoAnn Pushkin is executive director of DenseBreast-info, Inc., a 501(c)(3) public charity that supports DenseBreast-info.org, a web-based resource which provides breast density information to both patients and health care professionals. She can be reached at JPushkin@Dense-info.org.