The American Cancer Society has now released its newly updated Breast Cancer Screening guideline in the Journal of the American Medical Association
This guideline—which was last updated in 2003—reflects the American Cancer Society’s best thinking on breast cancer screening for women at average risk of breast cancer. They are not intended for women at high risk, such as those with genetic abnormalities (BRCA as an example), a personal history of breast cancer or a history of radiation therapy prior to age 30. That guideline is available on our website at www.cancer.org.
So let’s get right to the heart of the matter: what are the new recommendations?
- Women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 (Strong recommendation*)
1a) Women aged 45 to 54 years should be screened annually (Qualified recommendation*)
1b) Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually. (*Qualified recommendation)
1c) Women should have the opportunity to begin annual screening between the ages of 40 and 44 years (Qualified recommendation*)
2) Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (Qualified recommendation*)
3) The American Cancer Society does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (Qualified recommendation*)
*A strong recommendation conveys the consensus that the benefits of adherence to that intervention outweigh the undesirable effects that may result from screening. Qualified recommendations indicated there is clear evidence of benefit of screening but less certainty about the balance of benefits and harms, or about patients’ values and preferences, which could lead to different decisions about screening.
Obviously, there have been some changes from the prior guideline. And some of those changes may be a bit difficult to understand, both for consumers and physicians alike. Any time one changes a recommendation that has been offered to the public and widely adopted for so many years there are going to be questions and concerns. But ultimately we have to follow where the science and the evidence lead us—even though previous messages may have been deeply embedded in our thoughts and our routines.
Perhaps the most notable change is that we are now recommending that all women at average risk of breast cancer start screening mammography at age 45 instead of age 40. Bu there is an extremely important caveat that may not be coming through all the coverage. The guideline also says women at age 40 should have the opportunity to begin screening early if they so choose, based on their values and preferences.
Confusing? Well some people seem to think so, but the fact is that appearances can be deceiving. We believe the women in this country are fully capable of understanding these recommendations and making decisions that are best for them. In times past, doctors and others told us what to do. Today, we as consumers and patients should be part of the decision making process. Think of it as a roadmap with choices, and not a series of commands.
In the opinion of the guideline authors the evidence shows that the balance of benefits of screening mammograms—essentially the deaths avoided from not detecting a breast cancer earlier by doing a screening mammogram—is more favorable at age 45, while between 40 and 44 the balance is tipped ever so slightly, mostly because cancer is less common at these ages. What are the “harms?” They include the risk of a false positive, where a lesion or other abnormality is seen but no cancer is present; or getting an unnecessary breast biopsy. Simply stated, after reviewing the most recent evidence available the volunteer panel put together by the American Cancer Society concluded that the balance of benefits from routinely performing screening mammograms is greater for women ages 45 and older.
Once screening mammograms begin at age 45, they should be done every year according to the guideline. That is the same “frequency” recommendation that the Society has made previously. However, at age 55 the Society now recommends that women should decrease the frequency of screening mammograms to every other year based on the evidence reviewed. But here too there’s a critical caveat: women should continue to have the option to continue screening every year if they so choose, again based on their values and preferences.
The evidence shows that the risk of a cancer showing up between mammograms is reduced if done annually in the 45-54 age group (who more typically have faster growing breast cancers), while women 55 years of age and older have slower growing cancers that can be adequately detected by mammograms even if those mammograms are done every two years. There is virtually no statistical advantage to annual screening in post-menopausal women, based on Society’s assessment.
The guideline–as it did in 2003–offers a specific recommendation as to how long mammograms should continue. Once a woman reaches a point where her life expectancy is less than 10 years then there is no indication for screening mammograms to continue. There are too many studies that show mammograms being offered even when women have serious and even life-threatening illnesses. In these situations getting a mammogram doesn’t improve health, either from a medical or common sense perspective.
Finally, the guideline says that the Society no longer recommends that women should have a clinical breast examination (we have previously said the same about the use of formal breast self-examination). A clinical breast examination is when a health professional does a formal breast exam, typically as part of an annual physical. There is no evidence to show that this exam reduces deaths from breast cancer, and although some health professionals are very diligent in performing such examinations the reality is that many are not. As always, whenever a woman detects a change in her breast she should consult a health professional. Breast self-awareness remains a key to the successful detection and treatment of breast cancer.
Inevitably, there are going to be questions and disagreements about this new guideline. There will be concerns about what an individual woman should do, and whether there is going to be adequate access to mammography services.
The American Cancer Society still believes strongly that screening mammography is an important part of the early detection and successful treatment of breast cancer. However we also believe that as we learn more about the benefits and harms of mammography we have an obligation to share and recommend what we consider the best advice for the average risk women in the United States.
At the same time, we also need to emphasize that we still believe that if a woman between the ages of 40 and 44 wishes to have screening mammograms, she should have that opportunity. She should learn what the evidence says, and once informed should have the opportunity to have a screening mammogram if that is what she chooses to do. And for women age 55 and over, if they choose to have a mammogram every year they should also have an opportunity to get a mammogram every year. That should be their choice, and there should be no barriers put in the way of that choice.
It is not the intent of the Society’s recommendations to become a “one size fits all”. No one should lose sight of the fact that we believe strongly in shared decision making, and once fully informed if a woman makes other choices regarding screening mammograms, those choices should be honored.
Finally, there is something else that I have emphasized in the past and bears repeating at this time: mammograms save lives. They are an important part of a holistic approach to reducing deaths from breast cancer. However, mammograms do have limitations. They are not perfect. They do not detect every breast cancer early. Even if every woman got regular mammograms, breast cancer would remain a leading cause of cancer deaths. However we should not lose sight of the fact that mammography is an important part of the progress we are making and must continue to make in reducing deaths from this disease.
We must also remember that progress in reducing deaths from breast cancer also relies on self-awareness and taking action when you detect a lump in the breast. Better treatments for breast cancer have also had a significant impact on reducing deaths. Improving access to high quality mammograms and effective, appropriate treatment could also go a long way to reducing breast cancer deaths from this disease.
No matter how many mammograms we do, no matter how effective our treatments, there are women who still either present with advanced breast cancer or whose cancer—even if detected early—progresses aggressively. One can do “everything right”—and still develop advanced disease. We should not forget this, and we should never reduce our vigilance to develop and apply new approaches to breast cancer (and all cancers, for that matter) in our effort to diminish the impact of breast cancer on our nation and the world.
From a larger perspective, mammograms are an important part of a complex puzzle. Our hope is that these guidelines will further refine and improve one large piece of the puzzle. Better access to care, better application of what we know works in the treatment of breast cancer, better understanding that we still have too many women who present with regionally and more distant advanced disease—these all remain important parts of that puzzle.
It is incumbent on us to solve that puzzle in a way that offers the best opportunity of reducing the impact and improving the outlook for breast cancer for all women. These guidelines are a step, but there is still a long journey ahead of us to achieve that goal.