Screening Mammography: Moving toward a more personalized approach

Nov. 3, 2015

Take-Home Message:

The American Cancer Society provides new guidelines for screening mammography for average risk women. The American Society of Breast Surgeons responds and gives their recommendations for screening mammography.

 

Summary:

Breast Cancer Screening for Women of Average Risk: 2015 Guideline Update from the American Cancer Society
Authors: Kevin C. Oeffinger, MD; Elizabeth T. H. Fontham, MPH, DrPH; Ruth Etzioni, PhD; Abbe Herzig, PhD; James S. Michaelson, PhD; Ya-Chen Tina Shih, PhD; Louise C. Walter, MD; Timothy R. Church, PhD; Christopher R. Flowers, MD, MS; Samuel J. LaMonte, MD; Andrew M. D. Wolf, MD; Carol DeSantis, MPH; Joannie Lortet-Tieulent, MSc; Kimberly Andrews; Deana Manassaram-Baptiste, PhD; Debbie Saslow, PhD; Robert A. Smith, PhD; Otis W. Brawley, MD; Richard Wender, MD
Source: JAMA 2015;314:1599-1614. doi:10.1001/jama.2015.12783

On October 20, 2015, the American Cancer Society (ACS) published their new recommendations for screening mammograms.  In brief, the ACS recommends women have mammograms every year from ages 45-54 and then change to every other year at age 55 and continue this program until their life expectancy is estimated to be less than 10 years. Importantly, the ACS notes that women should consider mammograms between the ages of 40 and 44 once they have had a discussion with their physician or healthcare provider of the benefits and risks of mammograms in this age range. Similar to the publication in 2009 from the United States Preventive Services Task Force (USPSTF), which recommended women start screening at age 50 instead of age 40, there has been controversy about the proposed changes.  Currently mammograms are the primary method for screening large groups of women to find breast cancers when they are still small.  Screening mammograms have been shown to be effective at reducing the death rate from breast cancer because of their ability to find cancers at earlier stages.  There has, however, been concern about when and how often a woman should have a screening mammogram. One of the most important aspects of the USPSTF’s recommendations and those from the ACS is that they apply only to AVERAGE risk women.  

Defining who is AVERAGE risk remains a “gray” area for health care providers but is likely to become clearer over the next several years as research into “personalized” screening programs are published.  At this time, an example of an AVERAGE risk woman is one who has no personal history of breast cancer, no first-degree relatives (mother, sister, daughter) with breast cancer, and no prior chest wall radiation (such as for treatment of another cancer like Hodgkin’s lymphoma).  There are many women who are at intermediate risk and high risk for developing breast cancer for whom the new ACS screening protocols do not apply. It is for this reason that women need to discuss their personal risk of breast cancer with their physician or healthcare provider to determine if they should start screening mammograms at age 40.  

Based on review of the ACS guidelines and prior research on mammographic screening, The American Society of Breast Surgeons has updated their recommendations for screening.  These include the following:

  1. Discussion with her physician or healthcare provider to consider screening mammography at ages 40-44 based on a balanced conversation regarding the benefits and risks of mammography.

  2. Yearly screening for women ages 45-54 as indicated by the new ACS guidelines.

  3. Yearly or every other year screening for women 55 and older based on a shared decision-making discussion with their physician or healthcare provider regarding their benefits and risks of screening timing.

  4. Every other year screening for women over the age of 75 if an estimated life expectancy is greater than 10 years.

  5. If available, breast tomography, a new digital ”3D” mammogram, should be used as the screening method as it may reduce the number of ”false positives” or repeat mammograms needed because something was felt to be seen that wasn’t actually ”real.”

  6. Consider use of a risk assessment tool to determine an estimated lifetime risk for breast cancer.  The use of these risk assessment tools may help guide a woman in determining which mammogram schedule might be best for her.  

The American Society of Breast Surgeons' Consensus Statement

Icon Screening Mammography (165.9 KB)