Those Confusing Guidelines...

by Amanda Kappler, M.D.

      How often? When should I start? When can I stop? As a Brem Breast-Imaging Fellow, my patients ask me these questions about screening every day. Breast cancer screening guidelines have always been confusing. But recently they have become even harder to follow. I want my patients – and all women – to have a better sense of how to get properly screened so that they can maximize their chances of finding early, curable breast cancers. Here’s how to make heads and tails of the recent guidelines.

      Let’s lay out the organizational landscape: there are three main medical organizations that put forth recommendations about screening mammography: the American College of Radiology (ACR), the American Cancer Society (ACS), and the United States Preventive Services Task Force (USPSTF).[1] Differences in the recommendations are due to differences in each organization’s interpretation of evidence and judgment about the benefits versus drawbacks of screening. Doctors choose which recommendations to endorse for their patients.           

      When should a patient start? The ACR says to start at age 40, the ACS says to “offer” screening mammography between ages 40-44 and begin at 45, and the USPSTF says to start at age 50 but make screening an individualized decision between 40-49.  The differences reflect the way each entity values data.  The ACS and the USPSTF base their recommendations on death rates only.  The ACR, on the other hand, includes other known benefits of screening such as less aggressive surgery, less frequent and less toxic chemotherapy, and the detection and treatment of high-risk lesions.  Starting at age 40 with annual screening guarantees the greatest reduction in death rates from breast cancer –especially among younger women, the most lives saved, and the most life years gained[i].  One study showed that starting at age 40 with annual screening according to the ACR recommendations saves 12,216 more women’s lives each year than the USPTF recommendations which start at 50 with biannual mammograms[ii]

      Now that we’ve established that starting at age 40 saves the most lives, let’s discuss how often to get a mammogram. The ACR recommends mammograms every year, the ACS recommends mammograms every year between ages 40-54 but every two  years at or over age 55, and the USPSTF recommends every two years – regardless of age. I have seen too many patients who skip a year, for whatever reason, only to come back with a cancer that may have been detected the previous year. I tell all my patients to follow the recommendations of the ACR (and the Brem Foundation) by getting mammograms every year.

      Last but not least, when should you stop getting screened?  The ACR says to continue as long as you are healthy and want to be screened. This is the reasonable approach. The ACS says to continue as long as life expectancy is greater or equal to 10 years. That is a tough one for me. How do you predict that? How do you discuss this with patients? The USPSTF says to stop at age 74 with insufficient evidence for screening over age 75.  If this were the case, the patients who I have diagnosed with cancer over 75 would be missed. I think that beyond age 75, the decision to continue screening should be a shared decision-making process with the physician which includes a discussion on health status and longevity.

      Debates still rage between the entities that espouse different guidelines.  As a physician focused entirely on breast-imaging, I see everyday the tragedy of not being screened properly. I hope I have convinced you to follow the guidelines set forth by the American College of Radiology and the Brem Foundation – namely, for those at average-risk, to start at age 40 and get screened every year thereafter. The bottom line: annual screening mammograms starting at age 40 save the most lives. 

 

[1] The Brem Foundation follows the ACR guidelines.

 

[i] Lee CS et al. Harmonizing Breast cancer screening recommendations: metrics and accountability. AJR 2018; 210: 241-245.

[ii] Monticciolo DL et al. Breast cancer screening for average risk women-recommendations from the ACR commission on breast imaging. J Am Coll Radiol 2017: 14:1137-1143.