Mammography screening should be offered annually to women beginning at age 40 years, according to new breast cancer screening guidelines issued by the American College of Obstetricians and Gynecologists (ACOG). The new Practice Bulletin, entitled “Breast Cancer Screening,” is published in the August 2011 issue of Obstetrics & Gynecology. These guidelines replace the 2003 ACOG recommendations, which were that women should have mammograms every 1 to 2 years beginning at age 40 years, and every year beginning at age 50 years.
“Although women in their 40s have a lower overall incidence of breast cancer compared with older women, the window to detect tumors before they become symptomatic is shorter, on average,” said guidelines coauthor Jennifer Griffin, MD, MPH, in a news release. “If women in their 40s have annual mammograms, there is a better chance of detecting and treating the cancer before it has time to spread than if they wait two years between mammograms.”
The ACOG guidelines did not reach a consensus on the upper age limit for mammograms, but the potential benefits of screening decrease with advancing age, compared with potential harms of overtreatment. Dr. Griffin suggested that women 75 years and older discuss with their clinician the advisability of continued mammography screening.
American College of Radiology Responds
The updated ACOG guidelines agree with recommendations issued by the American College of Radiology (ACR), the Society of Breast Imaging, the American Cancer Society, and the American Society of Breast Disease. However, all of these differ from those of the United States Preventive Services Task Force (USPSTF), which states that among women 40 to 49 years, only those with a family history of breast cancer or other high-risk factors should be screened and that women 50 to 74 years should be screened every 2 years.
“The new ACOG recommendations are just another affirmation of the guidelines that the ACR and the American Cancer Society have stood by throughout the controversy,” Carol Lee, MD, head of the Communications Committee of the Breast Commission of the ACR and a practicing radiologist in New York, NY, told Medscape Medical News. “The new Practice Bulletin really does not cover any new data, but affirms and endorses the interpretation of that data by other professional societies, and we find this very gratifying. Our hope is that the new ACOG guidelines will emphasize the importance of annual mammography beginning at age 40 and that mammography saves lives.”
The ACR notes that the USPSTF relied largely on computer modeling to reach its conclusions but that there are no scientific data to support age 50 years as a biological threshold for screening. The ACR also suggests that the focus of the USPSTF was to reduce false-positive study results, most of which can be resolved by a few additional mammographic views or an ultrasound test.
“When we weigh the relative value of the benefits, namely saving lives, of implementing the new recommendations, versus the potential harms or risks, it comes out way in favor of starting annual mammography at age 40,” Dr. Lee said. “We feel that you can’t equate having a life saved with cost savings or reduction in unnecessary testing.”
nother argument advanced by the ACR is that 75% of women in whom breast cancer develops are not considered at high risk and that screening only high-risk women would miss three quarters of breast cancers. As previously reported by Medscape Medical News, a study by R. Edward Hendrick, PhD, and Mark Helvie, MD, published in the February issue of the American Journal of Radiology, analyzed the same data as did the USPSTF, but with a vastly different conclusion.
They showed that if USPSTF guidelines for breast cancer screening were followed, as many as 100,000 women, now 30 to 39 years old and preparing to enter screening age, would ultimately die unnecessarily from breast cancer. Women who receive annual mammograms starting at age 40 years could significantly reduce breast cancer mortality risk by 71%, whereas women following the USPSTF guidelines would only have a 23.2% reduction in mortality risk.
“The barriers to widespread implementation of the ACOG recommendations are those facing delivery of health care in general, namely issues of costs, coverage, and access, which are nothing new,” Dr. Lee said. “Depending on their community and their insurance coverage, some women may have to travel further or to wait longer to have their screening mammogram. But here we have a public health measure that works, and we should allocate health care dollars to screening mammography, and, if necessary, cut health care spending for measures that have not been shown to be as effective.”
A recent survey presented at ACOG’s 59th Annual Clinical Meeting indicated that women’s attitudes, in part influenced by media coverage, may actually favor implementation of the ACOG vs the USPSTF guidelines.
“Since the widespread introduction of mammography screening, breast cancer mortality has decreased,” Dr. Lee concluded. “This may not all be due to screening, but we know that tumors detected in early stages are associated with better survival.” Laurie Barclay, MD For original article, click here.
J. Kyle Mathews, MD
Plano OBGYN Associates
Plano Urogynecology Associates