Latest Mammography Recommendations

An influential federal panel issued its final recommendations Monday for when women should start getting mammograms, underscoring the conflicting advice on the issue coming from major cancer and women’s health groups.

One of those groups, the American College of Obstetricians and Gynecologists, or ACOG, has invited more than 30 organizations to participate in a conference later in January to try to reach a consensus opinion. It said many women have been confused by the groups’ disagreements, including on what is the best age to begin mammograms and how frequently to get them. 

The final recommendations from the U.S. Preventive Services Task Force say mammograms should be done every two years for women ages 50 to 74. Women in their 40s at average risk for breast cancer should consider the test depending on their comfort level. The recommendations, published in the journal Annals of Internal Medicine, are mostly similar to the task force’s previous guidelines, from 2009, but allow more leeway for women in their 40s to consider the test.

The American Cancer Society in October revised its own guidelines, pushing back the recommended start time for mammograms to age 45 from 40. It recommends the test every year until age 55, and then every two years.

Other influential groups, including ACOG and the National Comprehensive Cancer Network, a nonprofit alliance of leading cancer centers, recommend mammograms begin at age 40 and be done every year. 

Medical groups decide on guidelines by weighing the potential benefits of breast-cancer screening, mainly lives saved through early cancer detection, against possible harms, including false positives that can lead to unnecessary tests and treatment. Weighing the various factors differently can change the conclusions. The guidelines are designed for women of average risk.

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Nancy Keating, a primary-care provider at Brigham and Women’s Hospital in Boston, says in the past couple of years a “substantial” number of her female patients in their 40s have delayed getting regular mammograms to a later age. “Many women are confused [by the various recommendations] and it is challenging,” she says. Dr. Keating says she works with patients to assess their cancer risk and give them a sense of whether they are average or above-average risk.

Generally, recommendations from the Preventive Services Task Force must be offered as part of private insurance plans under the 2010 Affordable Care Act. To allay concerns about mammogram coverage, however, Congress added an exception to the law that requires insurers to cover annual mammograms starting at age 40.

Jill Rabin, an OB-GYN with Northwell Health System in Long Island, N.Y., says she follows the ACOG recommendations in advising most of her patients to start annual mammograms at age 40. She says getting screened every other year can lead people to miss a test “and that can be very, very dangerous because a lot can happen in that time.”

“I know that I’ve saved lives” by diagnosing patients with breast cancer who were younger than 45 and with no risk factors, Dr. Rabin says. “We can’t let these people down by postponing their chance at early detection.”

Experts have long stressed that early detection of cancer can save lives. Studies have estimated that annual screenings can cut the risk of death by 15% to 40%. Medical groups’ mammogram guidelines historically were largely in sync, but recent research has caused them to diverge. 

“We have tried to really clarify what the science is telling us about the benefits of mammography screening for women age 40 to 74,” says Kirsten Bibbins-Domingo, vice-chairwoman of the Preventive Services Task Force and a professor of medicine at University of California, San Francisco. While regular mammograms for women in their 40s are effective in reducing deaths from breast cancer, the benefit is less than it is for older women and the potential harms are greater, the task force noted.

Dr. Bibbins-Domingo says the task force’s latest recommendations aim to clarify its 2009 guidelines, which “were widely misinterpreted as a recommendation against screening for women in their 40s.”

An American Cancer Society study published in December in the American Journal of Preventive Medicine found that four years after the task force first stopped recommending mammograms for women in their 40s the prevalence of the tests didn’t significantly change for women in that age group. The study, which compared federal data from 2008 to 2013, the latest available, did find that there was a significant decrease in physicians recommending mammograms to women in their 40s. 

Therese Bevers chairwoman of the breast cancer screening and diagnosis guidelines panel for the National Comprehensive Cancer Network, says she plans to attend the ACOG conference on mammogram guidelines, but believes it may be difficult to reach a consensus among the various groups.

The conference, in Washington, D.C., is planned for Jan. 28 and 29. “We look forward to a positive outcome of this conference that helps to avoid the confusion that currently exists among the women we treat,” ACOG said Monday.

Dr. Bevers says she recommends women start annual mammograms at age 40. “We just feel that the task force placement on the harms is a bit excessive,” she says. Harms such as a false positive requiring a repeat ultrasound or a needle biopsy are outweighed by the potential for lives saved, she believes.

In a separate study also published in the Annals of Internal Medicine Monday, researchers found that false-positive results are highest among women 40 to 49 years old, leading to additional imaging. The study analyzed data from more than 400,000 women ages 40 to 89.

But Dr. Bevers says that based on clinical experience and research, after the additional tests performed following a false positive there is very rarely a wrong diagnosis.

Stephanie Nichols, a patient of Dr. Keating’s at Brigham and Women’s Hospital, decided around age 40 to wait until she turns 45 to have her first mammogram after learning she was at low risk for developing breast cancer. Ms. Nichols, now 44, says she was also influenced by talking about false positives and the additional testing and stress those can lead to. “I didn’t want to go through that,” she says. “I decided I would just keep doing breast self-exams and see her [doctor] regularly.”

The task force guidelines don’t specifically recommend regular mammograms for women 75 years and older and call for more research in this area. “There is not enough evidence for us to say with certainty what the benefit is,” Dr. Bibbins-Domingo says.

Susan K. Boolbol, chief of the division of breast surgery at Mount Sinai Beth Israel in New York City, disagrees with that conclusion by the task force. She says she presented research recently at the San Antonio Breast Cancer Symposium showing that mammograms in women age 75 and older are justified. 

Dr. Boolbol reviewed the mammography results of 2,057 women age 75 and older over two years at Mount Sinai. The breast cancer detection rate was 4.9 per 1,000 screenings, nearly double the rate the American College of Radiology uses as a standard for when mammograms should be used, she says.

“We should not base recommendations on an age limit,” Dr. Boolbol says. “It should really be based on the woman’s expected lifespan and her health status.”

SWY Comment:  Drs. Martin, Schrader and I have discussed the various guidelines for screening mammography.  We believe that for most women, the ACOG guidelines are most appropriate with the important caveat that all screening decisions (and particularly those in which there is controversy) should be made by the patient after discussion of risks and benefits with their physician.

By: Sumathi Reddy, The Wall Street Journal
Reviewed / Posted by: Scott W. Yates, MD, MBA, MS, FACP

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