New guidelines for mammograms released Tuesday by the American Cancer Society represent a significant step back from the aggressive early and universal screenings the country began 18 years ago.
The changes – which include raising the age that a woman of average risk begins regular screening from 40 to 45 – are a recognition of the growing concern that the benefits of mammograms may have been oversold, as well as the anxiety and needless treatments caused by overdiagnosis and false positives from the tests.
Richard Wender, a member of the breast cancer guideline panel and a former president of the ACS, said that the new recommendations confirm that mammography is the most important thing a woman can do to reduce her chance of dying of breast cancer but that they provide a more “personalized and tailored approach.”
“Over the past couple of years, there has been so much confusion that some women and some clinicians have really lost confidence in mammography. We hope this extraordinary and thorough review will calm that worry,” Wender said.
The more conservative approach outlined by the ACS calls for women starting yearly screening at age 45 and then transitioning to screening every two years starting at age 55 – which the panel used as a surrogate for menopause. It also recommended that doctors stop screening women with a life expectancy of less than 10 years based on the idea that they will likely die with the cancer but not from it. The recommendations are only for women who don’t have specific risk factors for breast cancer such as the BRCA1 and BRCA2 genetic mutations or a family history of the disease.
On Tuesday, breast cancer patient groups expressed alarm that the new guidelines – while not binding to doctors, hospitals or insurance companies – may lead too many women to skip life-saving screenings and provide an excuse for health plans to stop covering them as much as they currently do.
“We are worried about the message and confusion to the public when they see these new guidelines. The cut back on screening is falsely reassuring,” said Marisa C. Weiss, an M.D. who is the founder and president of Breastcancer.org.
Judy Salerno, president and CEO of Susan G. Komen, said she’s “concerned that they have the potential to lead to reduced accessibility to and coverage for health screenings from both private and public insurers.”
The ACS’ updates come at a time when cancer experts are rethinking the very definition of cancer. Thanks to advances in genetic testing, blood-based markers and digital imaging, cancer is being diagnosed earlier than ever and there’s a radical new recognition that there are subset tumors that are detected but may never grow enough to be harmful to a patient. The most obvious example is in prostate cancers, but researchers have found similar cases in cancers of other regions.
Mammograms, X-rays of the breast that have been used for more than a century to pinpoint irregularities in the tissue, are credited with saving many millions of lives by catching cancers at their earliest stages. Breast cancer is one of the leading killers of women in the United States, with approximately 225,000 diagnosed each year and 41,000 dying from the disease. In part because of the ubiquitous pink ribbon-themed races, T-shirts and stuffed animals of breast cancer fundraisers and in part because of stories like Angelina Jolie’s, many women have come to believe that the more screening and the more treatment the better.
But a number of new studies have questioned this idea.
In July, for example, a re-analysis of data from a pivotal paper based on women in the 1960s and ‘70s in Sweden showed that screening could reduce deaths around 10 percent – rather than the 20 percent to 25 percent that had been originally claimed. And in August, a study in JAMA Oncology found that the overall risk of dying after being diagnosed with so-called stage 0 or ductal carcinoma in situ (DCIS) cancer was 3.3 percent over two decades and that pursuing treatment beyond a lumpectomy did not affect survival.
The ACS is one of a number of organizations whose recommendations are hugely influential in how doctors treat their patients. The U.S. Preventive Services Task Force, an independent panel of experts whose members are appointed by the federal government, reaffirmed their view this April that women between ages 50 and 74 get routine screening once every two years. The American College of Obstetricians and Gynecologists still recommends that regular screenings begin at age 40.
That means that now the three different groups are recommending three different ages – 40, 45, and 50 – when regular breast cancer screening should begin.
Nancy L. Keating, a doctor in internal medicine and primary care at Brigham and Women’s Hospital who wrote an editorial in JAMA, formerly the Journal of the American Medical Association, accompanying the new guidelines, said the discrepancy shows how controversial the subject of mammograms can be.
In an interview, Keating said that here you have several groups of “very smart people who looked at the same body of literature.” “If there were an easy answer they would all have the same conclusions,” she said. “It underscores the uncertainty.”
Keating said the debate is global.
In Britain, screenings are recommended every three years starting at age 47. In Canada, it’s age 50 every two years. The United States is one of the only places in the world that recommends annual screening at any age.
“They are saying that they realize we now need to think about the balance of benefits and harms for each individual when we’re making decisions about who to test. It’s no longer as simple as saying everybody needs a mammogram,” said Keating, who is also in the department of health-care policy at Harvard Medical School.
Wender said that the approach by some countries with national health-care systems is a “resource decision” because they pay for the screenings, whereas the threshold in the United States is different because they are guidelines for individuals.
“It reflects the high value that women and the nation have on the opportunity to prevent a cancer death,” he said.
Part of the reason for the changes in the guidelines is that a woman’s risk of breast cancer increases as they age. Before age 34, their risk is 0.2 percent over five years, 35-39 0.3 percent and 40-44 0.6 percent. But at 45-49 the risk climbs to 0.9 percent, at 45-49 1.1, 50-54 percent 1.1 percent, 55-59 1.3 percent, 60-64 1.6 percent, 65-69 2 percent and 70-74 at 2.1 percent.
The ACS guidelines also include a recommendation against routine clinical breast examination – a major change for many women who are used to getting one during their annual physical exams. Wender said that doesn’t mean the organization is telling or asking physicians to stop doing them.
“What the guidelines are saying is that it is mammography that really reduces the risk of breast cancer because it finds them before anybody can feel them,” he said.
In looking at the ACS' explanation of its updates, Daniel Kopans, a professor of radiology at Harvard Medical School, noted that the “emotional effects” of being recalled to undergo more testing was one reason given. That’s because mammograms can sometimes show areas that look like masses but turn out to be nothing after a second imaging or a biopsy.
“They seem to have wanted to account for the inconvenience of a recall from screening to suggest that some women might prefer to chance an avoidable death for a reduced chance of being recalled for a few extra pictures or an ultrasound,” he said.
Kopans said he will not be changing his approach to mammograms based on the new guidelines, pointing out that both the ACS and the USPSTF still agree that the most lives are saved by annual screenings at age 40.
“I support the science which is every year starting at age 40,” Kopans said. “This is my recommendation.”