Mammography image by Blausen.com staff at creativecommons.org
The American Cancer Society on Oct. 20 issued new guidelines for breast cancer screening that conflict with its earlier recommendations and those of other cancer research groups. What does this mean for women?
It means women should talk to their doctors and decide for themselves when to start getting an annual screening mammogram and how often to do so.
There is no one-size-fits-all recommendation, said Carolyn Bruzdzinski, PhD and VP of the American Cancer Society’s Lakeshore Division in Chicago, in an email conversation with Daily North Shore about the new guidelines. “The recommendations offer a roadmap based on a woman’s age, health, and personal values and preference.”
The ACS now recommends women should start getting annual screening mammograms at 45 – not 40, as the ACS previously recommended, or 50, as the U.S. Preventative Services Task Force suggests. The ACS also recommends women age 55-plus should switch from annual to every-other-year screenings. And it now says women can do away with regular clinical breast exams and monthly breast self exams.
What’s behind the changes? Dr. Bruzdzinski addressed this and several other questions by Daily North Shore; here are her answers, followed by another Q&A with the clinical director of Northwestern Lake Forest Hospital’s Breast Care Program, Dr. Tara M. Breslin.
Carolyn Bruzdzinski
Daily North Shore: Why is the ACS releasing these guidelines now? Is the information new?
Dr. Carolyn Bruzdzinski: A considerable amount of new data has emerged since our last review in 2003. Since then new information has accumulated both on the quality and effectiveness of mammography, as well as the risks associated with screening. The new guideline for average-risk women is the result of a rigorous review of the data, taking into account not only the benefits of screening, but also the risks in getting screened.
Daily North Shore: Why did the ACS settle on age 45 instead of 40, as recommended by the American Congress of Obstetricians and Gynecologists, or 50 as suggested by the U.S. Preventative Services Task Force?
Dr. Bruzdzinski: The evidence clearly supports starting annual screening at age 45. The guideline is aimed at maximizing mammography’s ability to save lives from breast cancer while minimizing the harms of false positives, additional procedures, and potential over-diagnosis. Because the evidence does not support a ‘one size fits all’ recommendation, the recommendations offer more tailored guidance based on a woman’s age, health, and personal values and preferences. Every woman should talk with her doctor.
The ACS Guideline Development Group looked at five-year intervals, rather than the 10-year intervals analyzed by the other two groups. By doing this, they found that the risk of getting breast cancer in the age group from 45-49 and the group from 50-54 was very similar, and that the balance of the benefit of screening (because of the frequency of the disease) and the risk of harms from screening is the same, therefore, the direct recommendation is to begin screening at age 45, not 50.
In the age group of 40-44, the risk of cancer is lower and the risk of harms somewhat higher. Therefore, it was concluded that the direct recommendation for screening should be 45. HOWEVER, because there continues to be some benefit to screening in the 40-44 age group, the guideline group supports a woman’s choice to be screened at that age, based on her and her health provider’s assessment, preference, and the trade-off of benefits to risks.
Daily North Shore: If you are 40 and have already started getting annual screening mammograms, is the recommendation to now stop and wait until 45?
Dr. Bruzdzinski: The recommendations support a woman’s choice to be screened beginning at age 40, following a conversation with her doctor. This applies whether a woman in this age group is considering beginning screening, or if she has already started annual screening.
Daily North Shore: How do the new guidelines affect women who have a family history of early onset breast cancer — and just for clarity and to remind people, who constitutes at risk? Is it women with an immediate family member (mother, grandmother, aunt, sister?). Are there other factors that put a woman at risk of breast cancer?
Dr. Bruzdzinski: This guideline is only for women of average, not high, risk of breast cancer. The elements that constitute risk are complex and that is the reason it is so important for a woman to have the conversation with her doctor. Family history, breast density, when you had your children, and several other factors can all contribute to increasing your risk for breast cancer. Carrying the genes BRCA1 and BRCA2 would put you in a high-risk category, as would exposure to radiation to your chest (for cancer treatment for example). It’s very important to have a conversation with your doctor about your risk and your personal values when you reach age 40 and are considering screening.
We also encourage people to visit cancer.org for information about breast cancer, risk and screening.
Daily North Shore: Studies also have been released lately about mammography’s limitations for dense breasts. Should women with dense breast tissue continue to get mammography? And if so – how often? If it is harder to read their mammograms, should they be on the every-year plan? Or conversely, should they not even get mammograms? Or is there another guideline for them?
Dr. Bruzdzinski: Breast density is a factor when considering mammography. The American Cancer Society will be updating the guideline for high-risk individuals and I anticipate that this category will be included in those discussions. Women should talk with their doctors about when to begin mammography, how often, and what the best test is for them, based on their personal history, age, health, and personal values and preference.
Daily North Shore: What about radiation and mammography and cancer, which also has been in the news in recent years. Does mammography increase your risk of getting breast cancer or another type of cancer?
Dr. Bruzdzinski: The Guideline Group concluded from a review of the evidence that exposure to radiation from mammography was not a risk that should be considered when deciding what age to begin ammography. That is different from having had radiation treatment to the chest. The exposure from radiation treatment to the chest (for example for Hodgkin’s Lymphoma) does place an individual in the high-risk category. Again, we encourage every woman to talk with her doctor.
Daily North Shore: I notice that in almost all of your answers, you say that women should talk to their doctors and decide for themselves. Given that — why does the ACS even provide a guideline for what age to start mammography screening?
Dr. Bruzdzinski: It is always important to have discussions with your doctor concerning your health. Because many factors influence the risk to develop breast cancer, discussions with your doctor can help you determine your own personal pathway for screening. The ACS publishes guidelines to better inform that discussion. They really serve as a roadmap to assist individuals in making those decisions. Based on the evidence, it is clear that average risk individuals should begin screening at the age of 45, at the minimum. They can, however, after discussion with their physician, decide to begin screening earlier at the age of 40. The ACS supports both of those decisions. Likewise, the evaluation of the evidence by our experts demonstrated that individuals should not delay screening until age 50.
Daily North Shore: Finally, can insurance companies now opt out of paying for mammography screening for women 40 to 44?
Dr. Bruzdzinski: As an organization, the American Cancer Society and it’s advocacy affiliate, the American Cancer Society Cancer Action Network (ACS CAN) has long advocated for coverage of screening on an annual basis from age 40. We will continue to robustly advocate for that coverage, as our guidelines support the decision of women to begin screening early and to continue screening on an annual basis for the rest of their life, as long as they remain in good health.
Tara M. Breslin, MD, FACS
Clinical Director Breast Care Program Northwestern Lake Forest Hospital
Dr. Tara Breslin
Daily North Shore: Why is the ACS releasing these guidelines now? Is any of the information “new”?
Dr. Tara M. Breslin: The last ACS breast cancer screening guidelines for women with normal breast cancer risk were released in 2003. These guidelines were due for updating based on new data and are based on a rigorous review process adopted by the ACS to ensure transparency in the guideline development process.
Daily North Shore: Why did the ACS settle on age 45 instead of 40 (American Congress of Obstetricians and Gynecologists) or 50 (U.S. Preventative Services Task Force)?
Dr. Breslin: The ACS panel took a detailed look at the evidence, examining the burden of disease and the benefits of screening in 5-year age groups (e.g. 40-44, 45-49, 50-54) In addition, the ACS group placed greater weight on modern day observational studies conducted since 2000 to supplement earlier data from randomized controlled trials. The USPSTF relied more heavily on mathematical modeling and somewhat discounted the findings from observational studies as less reliable compared with the randomized trials. Two observations influenced the ACS guideline development group’s decision to recommend screening at age 45. First, the burden of breast cancer was very similar in women ages 45-49 compared with women ages 50-54. Second, modern evidence suggests that the benefit of screening is similar at age 45 to the benefits at 50, as are the odds of experiencing a false positive finding.
Daily North Shore: What is your recommendation for mammography and why?
Dr. Breslin: I recommend that women review these guidelines with their primary care provider and determine how the guidelines may or may not affect their individual situation. These guidelines only address women with average risk for breast cancer without high risk conditions or family history. These recently released guidelines are an opportunity for women to address the issue of breast cancer risk with their doctors and use this information in formulating their screening schedule.
Daily North Shore: What is your recommendation for monthly self exams and why?
Dr. Breslin: I recommend that women continue to be aware of their bodies and monitor themselves for changes. If a woman notes a change in her breast, she should bring it to the attention of her doctor.
Daily North Shore: What is the chance that breast cancer screening will save a life?
Dr. Breslin: It is important to remember that the goal of a breast cancer screening program is to detect abnormalities in women without symptoms. The patients with symptoms or a pre-existing problem identified on mammography are a different group, and these guidelines do not apply to them. The challenge of population-based screening is maximizing the lifesaving benefits of screening and minimizing the potential down sides such as false positive mammograms, anxiety, and lost time from work due to diagnostic workups.
Daily North Shore: What about breast density? What is the value of mammography for women with dense breasts?
Dr. Breslin: Mammography continues to have value and does detect cancer in women with dense breasts. Dense breasts are very common and women with dense breasts may benefit from using advanced mammographic screening techniques such as tomosynthesis.