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ACS updates breast cancer screening guideline for average-risk women
Women with an average risk for breast cancer should undergo regular screening mammography beginning at age 45 years, according to an updated guideline from the American Cancer Society published in JAMA.
Further, the guideline recommends women aged 40 to 45 years should have the opportunity to begin screening, and women should transition to biennial screening at age 55 years with the option to continue annual screening.
Although the number of breast cancer deaths have been steadily declining for the past quarter century, it remains the second-leading cause of cancer death among women in the U.S. Approximately 230,000 women will be diagnosed with breast cancer and an estimated 40,300 women will die from the disease in 2015.
Robert A. Smith
“Prior to this update, our most recent guideline for breast cancer screening in average risk women was published in 2003,” Robert A. Smith, PhD, cancer epidemiologist and senior director of cancer control at ACS, as well as an adjunct professor of epidemiology at the Rollins School of Public Health at Emory University School of Medicine, told HemOnc Today.
That guideline recommended women undergo annual screening beginning at age 40 years.
“Since, 2003, a considerable volume of new data has emerged, including both updates of the randomized trial data, but especially observational studies of population-based organized screening and modeling studies," Smith said. “There also is more emphasis on considering not only the benefits of screening, but also the downsides, considering each in making recommendations, and allowing for individual values and preferences in some of the decisions adults make about screening when the balance of benefits to harms is less certain."
Updated guidelines
The guidelines are intended for women with an average breast cancer risk, or women without a personal history of the disease, a suspected or confirmed genetic mutation known to increase breast cancer risk, or a history of chest radiotherapy at a young age.
The ACS strongly recommended — which indicates that the benefits outweigh the harms that could result from screening — regular screening for women with an average risk for breast cancer beginning at age 45 years. The guidelines offered a qualified recommendation —indicating that there is a clear evidence of benefit, but less certainty about the balance of benefit and harm, or a patient’s values and preferences — that screening in women aged 45 years should occur annually.
The ACS also offered qualified recommendations that:
- Women aged 55 years and older should switch to biennial screening but have the opportunity to continue annual screening if they so choose;
- Women aged 40 to 44 years should have the opportunity for annual screening;
- Mammography screening should continue for women as long as they are in good health or have a life expectancy of at least 10 years; and,
- Clinical breast examinations for breast cancer are not recommended for average-risk woman of any age.
“Some aspects of our guideline have changed, but each recommendation either has been reinforced or modified due to the data that have accumulated in the last decade,” Smith said. “In every respect, this new guideline is grounded in the evidence, including those periods in the early 40s and after age 55 years when women have options based on their values and preferences. We think this is an important feature.”
Decision to screen
In an accompanying editorial, Nancy L. Keating, MD, MPH, professor of health care policy and medicine at Harvard Medical School and a physician at Brigham and Women’s Hospital, and Lydia E. Pace, MD, MPH, a physician specializing in women’s health and internal medicine at Brigham and Women’s Hospital, questioned whether these new guidelines will simplify screening decisions for women and their clinicians.
Nancy L. Keating
“In some ways, the messages from ACS and the U.S. Preventive Services Task Force [USPSTF] — two major guidelines — are now more consistent,” they wrote. “Both guidelines agree that for average-risk women younger than 45 years, the harms of mammography screening likely outweigh the benefits. The new ACS recommendation to stop screening older women with life expectancies of less than 10 years is practical and consistent with the increasing emphasis on functional vs. chronological age.”
However, Keating and Pace pointed out there is still discordance between the ACS and USPSTF recommendations for women ages 45 to 54 years.
“ACS recommends annual screening but … the USPSTF recommends no routine screening (ages 45-49 years) or biennial screening (age 50-54 years),” they wrote. “In communicating with patients, clinicians will have to balance the ACS’ recommendation for more frequent screening against the fact that younger women experience a lower absolute benefit from screening mammography.” – by Anthony SanFilippo
Disclosure: Smith reports no relevant financial disclosures. Please see the full study for a list of all other researchers’ relevant financial disclosures. Keating reports serving as medical editor for the Informed Medical Decisions Foundation, part of the nonprofit Healthwise. Pace reports no relevant financial disclosures.
Perspective
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The American Cancer Society published new guidelines based on a systematic evidence review of breast cancer screening literature including randomized controlled trials (RCTs), more recent observational studies and simulations.
It is admirable that newer observational studies were included, since the randomized trials are now over 30 years old.
One important finding is that all these studies show “a reduction in breast cancer mortality across a range of study designs, including RCTs and observational studies (trend analyses, cohort studies and case-control studies), with most studies demonstrating a significant benefit.”
However, a fundamental assumption of the analysis is that all women are at the same risk and will all have the same outcomes if they do develop breast cancer. Of course, this cannot be true; on the therapeutic side of breast cancer we have recognized that there are many molecular subtypes, and each subtype has a different prognosis and biology. Different therapies are used based on the subtype of breast cancer. Increasing molecular detail of breast cancer is leading us into an era of “precision” medicine, where more or less therapy is prescribed based on a better understanding of a patient’s tumor.
Why shouldn’t the same paradigm apply to breast cancer screening? We need further research into risk assessment and screening technology in order to provide “precision” prevention strategies — including the use of breast imaging. For example, we know that screening a woman with a BRCA mutation under these new guidelines would be wrong and mammography alone may be insufficient. Identifying other risk groups would improve our screening strategies.
Until then, the existing guidelines, including the new ACS guideline, represent an honest effort to synthesize existing data; however, at the same time, we know that they cannot be right based on what we know about breast cancer.
Women and their care providers must have a detailed discussion on what is known today to make an informed decision.Perspective
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The U.S. Preventive Services Task Force (USPSTF) recommends women begin screening at age 50 years, and now the American Cancer Society recommends screening commence at age 45 years, with a switch to screening every other year at age 55.
However, the American College of Obstetricians and Gynecologists and the National Comprehensive Cancer Network — as well as major breast cancer centers, including Memorial Sloan Kettering Cancer Center and The University of Texas MD Anderson Cancer Center — are not changing their guidelines from age 40 years. That is because there is absolutely no question that there is an extensive body of literature that supports screening at age 40 years.
It is plausible to screen every-other year when aged 40 to 50 years and then annually thereafter. However, the problem with saying this to women and their health care providers is that an interval of 1 year would eventually become 2 years, which will become 5 years, which will become 10 years.
Unfortunately, these guidelines may be motivated by insurance companies and lobbyists. It is very unfortunate that we’re going to take a major screening test — that, without a question, saves lives — and embark upon health care rationing with it.
Also frightening is the fact that no one is willing to discuss the occurrence of breast cancer in even younger women. The national numbers always lag years behind by the time data are collected and circulated, but many more women in their late 20s and 30s are being diagnosed with breast cancer, and this too warrants much-needed attention.
Saying women have the opportunity to commence annual screening at age 40 years is a slippery slope. Insurance companies rely heavily on what the ACS recommends. This alleged “opportunity” to begin screening at age 40 years is not going to be an opportunity at all, but rather, it opens the door for insurance companies to deny women this option.
Further, the data based on this guideline update appear flawed. The biggest issue is that the society is resting their laurels on the fact some women who are screened when aged 40 to 45 years receive false-positive results, which they imply could traumatize women. This may then lead to biopsies, which they imply would be horrific.
However, almost every woman would say that the most horrific thing would be to miss the screening and diagnosis altogether — causing a delay in treatment, which in turn could result in a potential mastectomy, chemotherapy and ultimately a change in their survival.
Further, the ACS data are so outdated that they are not looking at 3D and digital mammograms, which decrease the risk for false alarms, callbacks and biopsies. These data are based on old mammograms — that’s like comparing your television set from the 1970s to the televisions of 2015. We can see these mammograms better and more clearly now, and therefore we have fewer callbacks.
Nobody is asking the patients what is worse — a callback for a false alarm, or missing a diagnosis and delaying treatment? There are so many layers to this, and these ACS guidelines and the USPSTF guidelines are only looking at the superficial layer.
Our job as health care providers is to guide and advise our patients, provide them with recommendations and inform them of their options. The onus is on us is to tell them what they need. We need to be leaders and tell them that they need a mammogram at age 40 years and beyond.