On Tuesday, the American Cancer Society (ACS) released its updated breast cancer screening guidelines to recommend that women at an average risk of breast cancer should wait to undergo annual screening mammography until they reach the age of 45. After age 55, the guideline recommends transitioning mammography to every other year.
Prior ACS guidelines recommended that annual screening should begin at age 40. In this update, screening for women age 40 to 44 is listed as a personal choice rather than a strong recommendation. For women over the age of 55, annual screening is listed as a choice, rather than a recommendation, in favor of biennial (every other year) exams. The new guideline did not place a maximum age on screening, as long as life expectancy was greater than 10 years.
To gain insight into these updated guidelines, CURE spoke with our editor-in-chief, Debu Tripathy, who is also the chair of the Department of Breast Medical Oncology at The University of Texas MD Anderson Cancer Center.
What is the impact of these new guidelines?
The area of breast cancer screening has been in flux for some time. If you look at the benefits from screening mammography and look at the number of lives saved — there’s some disagreement with what the exact numbers are — it’s estimated that in younger women, you may have to screen 1,000 women to impact one life. This comes at the impact of many false-positive tests, causing a lot of people alarm and, in some cases, even surgery and biopsies. Even with a true positive diagnosis of breast cancer, it may be a very slow-growing cancer that may not have caused any problems for a patient. It’s very hard to measure all of this, though. The question remains: Are we really helping people that much or are we putting them through too much? That’s one side of the argument.
The other side of that argument understands all of this — that mammograms aren’t perfect and that sometimes we may do unnecessary biopsies or treat patients unnecessarily — but in the end, we are saving lives.
To put this in context, with pap smear screening to detect cervical cancer, especially in high-risk individuals, the benefits are profound — it really cuts the rate of fatal cervical cancers. Even lung cancer screening in smokers has been found to be more effective and this is something that wasn’t being done really until a few years ago. Prostate cancer screening is in the same boat as breast cancer, though possibly with even more uncertainty. In prostate cancer, there’s a question as to whether anyone derives a survival benefit. In breast cancer, at least for people between the ages of 50 and 65, most physicians agree that there is a benefit to screening.
Where do you stand on this?
First of all, there’s always going to be an element of confusion because people will always disagree about the benefits and harms of screening.
I still feel that screening helps, in general, but I think women have to be informed about the consequences of screening. They have to understand that it’s possible that their mammogram may be abnormal, which may alarm them, and that the follow-up involves additional imaging. It may then have to proceed to a biopsy. In the U.S., only one in three biopsies end up being positive. Even if cancer is picked up, it’s possible that it’s such a low grade disease that it has a low chance of being fatal. However, we may still recommend fairly aggressive treatment, including chemotherapy because we can’t be 100 percent sure that a cancer is low-grade and won’t spread. As physicians, we almost always err on the side of additional treatment. All of this has to be discussed with patients and we need to do a better job of public education.
When patients buy into the idea of screening, they need to know the whole picture. What I don’t want is a person who undergoes screening and then they’re called back for other tests and things they didn’t anticipate. Patients need to understand the general statistics of breast cancer, too, and it’s something that we, as physicians, can explain to patients.
There are many things in life that are complicated and uncertain that people understand. When a hurricane is coming, people look at weather maps and the path that the hurricane might take, but they understand that it could turn at any time — people understand this. When it comes to health, people understandably tend to get more invested. Biological systems are as complicated and unpredictable, if not more so, than weather systems.
The new guideline pushes back annual screening for women at “average risk” from age 40 to age 45. How does risk assessment factor into these guidelines?
Many people talk about how we should do risk-adjusted screening — the idea to only screen patients at higher risk of developing cancer or that the age at which one starts screening is based on how likely they are to get cancer.
The problem is that none of the guidelines — ACS, U.S. Preventive Services Task Force, etc. — specify how to determine risk. In fact, it turns out that most breast cancers are diagnosed in patients that don’t have any other risk factors. As physicians, we agree with the concept of risk-stratified screening, but we don’t have the tools to assign risk as well as we’d like to.
What’s the importance of self breast exams?
Self exams have never been shown to be helpful and there have been numerous studies done both in the U.S. and other countries. It’s never been proven that people who are educated about self exams and perform them have earlier detection or better outcomes. Most physicians now understand that the monthly shower exam we used to advocate for probably isn’t helpful.
I do tell women to be aware of their breasts and their bodies and bring any changes they notice to the attention of a doctor.
Do you think these new guidelines will have any effect on how insurance companies cover screening?
I don’t think so. These guidelines still give women the option to start screening earlier based on an informed discussion with their physician. I don’t foresee that insurance companies will start to limit what they cover. It could affect co-pays or reimbursement, but there won’t be any major changes beyond that. Of course, you never know what the insurance industry will do.
What’s the key takeaway here for our readers?
Mammography is not perfect. It’s not going to detect every cancer and sometimes it produces a false alarm. Most studies support the idea that early detection is better so we, as physicians, think individuals should avail themselves to screening in their 40s or at age 50.
People need to know the statistics — of a false-positive, of a real cancer and of detecting a cancer that may not have needed treatment. These are all things women need to be aware of, so they go into the screening process with their eyes wide open
I was 69 years old when I was diagnosed with invasive ductal breast cancer. I had had mammograms faithfully each year except the year before my diagnosis due to a move out of state. The previous mammogram was clear but in 2 years I had developed cancer. The new guidelines are saying mammograms are only needed every other year after age 55. This makes me livid. Cancer has no timetable. We have come so far in research and early detection of breast cancer and a reduction in the mortality rate from this insidious women's cancer and now we are being asked to take a step back. Believe me the emotions experienced in a "false positive" report have no comparison to sitting in a surgeon's office hearing that you indeed have an invasive tumor in your body which will require surgery, chemo, radiation and years of adjuvant therapy.
I see this as something to prepare us for insurance companies refusing needed mammograms. I do hope this decision will be reversed as many women realize they are being duped.
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