You’re 40. Should you get a mammogram or not?
This story was fun to write because it was a quick response to a very confusing change in guidelines issued from a prominent healthcare advisory group. Their influence is profound and often guides what is and is not covered by insurance. I had the chance to read the study from which the new breast health screening guidelines were taken, and it was not so straight-forward. It didn’t take long to uncover the fact that the advisory board included a few healthcare economists – a signal that the financial cost of the test was central to the findings. Sometimes you need to read between the lines and doing this article allowed me to do so.
– Claudia Dolphin
The American Cancer Society made a surprising announcement this week, calling for less frequent breast cancer screening in younger women and the abandonment of routine manual breast exams all together.
It was a remarkable shift from a well-respected organization known for its advocacy of aggressive early detection and prevention measures.
The Cancer Society released its new guidelines after an exhaustive review of breast cancer screening studies since 2000. They were published Oct. 20 in the Journal of American Medical Association. The Cancer Society now recommends that:
- Women with an average risk of breast cancer should start having annual mammograms from age 45 to 54, instead of beginning at 40. But women should be allowed screening at age 40 if they want it.
- At age 55, women should get a breast cancer screening every other year, or as long as they remain healthy and likely to live 10 more years. They, too, should continue annual screening if that’s their preference.
- Performing annual clinical breast exams, where breast tissue is felt manually, was found to have no benefit and should be discontinued.
The Cancer Society defines average risk for breast cancer as women with no personal history of breast cancer, no confirmed or suspected genetic mutation known to increase risk of breast cancer, such as BRCA and no history of previous radiotherapy to the chest at a young age.
Infographic via Society of Breast Imaging
Anne Morris, MD, a radiologist at Cape Cod Hospital, said she was surprised by the revised guidelines. “This is just going to confuse women even more,” she said. “We now have three conflicting guidelines.”
In addition to the Cancer Society guidelines, the U.S. Preventive Service Task Force recommends biannual breast screenings at age 50 and 74. The American College of Radiology and Society of Breast Imaging says annual screenings should begin at 40.
“Do I start at age 40, 45, 50?” Dr. Morris asked. “Do I go every year? Women don’t know what to do.”
She said the new Cancer Society guidelines are based on the number of false positive results that lead to women being called back for a second test.
Mammography has a relatively high false positive rate. This is especially true in younger women, whose dense breast tissue makes detection difficult. When this happens, women are subjected to additional tests that may cause emotional and physical distress.
But Dr. Morris said the number of callbacks is not enough to change the guidelines.
“Only 10 percent of women who get mammograms are called back, only 1 to 2 percent go on to have biopsies and most of the time they are told everything’s fine,” she said.
“What’s better, to try and avoid some anxiety, or save a life of a 40-year-old? These are women with kids who have 40 or 50 years ahead of them,” she added.
Michael Fishbein, MD, radiologist at Falmouth Hospital agrees that the revised guidelines place too much emphasis on the harms of false positives and do not justify abandoning the traditional, more cautious approach.
“This shows a complete bias among the investigators,” he said. “They are worried about the negative consequences a woman might face when asked to come back for additional views or follow-up care. In no other areas of diagnostics is this remotely a concern. You do it because the risks are too great not to.”
All three organizations agree that mammography saves lives. The Cancer Society reports that deaths from breast cancer decreased by 34 percent from 1990 to 2010. The decline has been faster among women under age 50, proving that early detection makes a huge difference.
“Catching it early saves lives and reduces the extent of surgery and the need and extent of additional therapies,” said Dr. Morris.
Dr. Fishbein also questioned the decision to suspend clinical breast exams. “There are two ways to detect breast cancer—by seeing and by feeling,” he said. “It makes no sense at all to say not only do we think that screening by mammography should happen less often, but we also endorse abandoning feeling it manually.
“We know that the sooner cancers are found, the better the outcome. Size matters! Both [tests] are vital tools in early detection.”
The study data was not well represented by screening with tomosynthesis (3D mammography) due to its newness to market. Tomosynthesis provides a much clearer picture, and studies have shown a greater rate of detection with fewer false positive results.
Dr. Fishbein said this technology is quickly becoming a cost effective screening tool, and is showing a superior ability at detection. “Let’s hope that the emergence of MRI technology will end these silly discussions.”
This year, the Cancer Society estimates that 231, 840 women in the United States will be diagnosed with breast cancer and 40,290 will die from the disease.
Both Dr. Morris and Dr. Fishbein advise healthy women with average risk to start annual mammography at age 40. To determine your risk, use the American Cancer Society’s breast cancer risk assessment tool, and discuss any concerns over the revised guidelines with your primary care provider.