mammography

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What You Should Know About The New Breast Cancer Screening Guidelines

The American Cancer Society has issued newly revised guidelines on mammography and breast cancer screening. Here a woman is screened in Los Angeles in 2010. (Damian Dovarganes/AP/File)

The American Cancer Society has issued newly revised guidelines on mammography and breast cancer screening. Here a woman is screened in Los Angeles in 2010. (Damian Dovarganes/AP/File)

If you follow women’s health, there’s big news today from the American Cancer Society, which just issued newly revised (and frankly head-spinning) guidelines on mammography and breast cancer screening. Why all the fuss? Because breast cancer is the most common cancer among women worldwide; in the U.S., about 230,000 cases are expected to be diagnosed in 2015 with an estimated 40,300 deaths. And when such an influential organization changes its recommendations, it can radically shift the conversations between doctors and patients.

Here’s the crux of the news: In 2003, the ACS recommended annual mammography screening for all women starting at age 40 and continuing as long as women remain healthy. The group also recommended clinical breast exams (CBE), which is simply when your doctor examines your breasts, periodically for women in their 20s and 30s and every year for women 40 and up.

The new recommendations, published Tuesday in The Journal of the American Medical Association, change all of that, and come at a time of growing awareness about the potential downside of screening and the harms of over-diagnosis.

Here are the new guidelines from the report (my bold added):

The ACS recommends that women with an average risk of breast cancer [no family history, genetic predisposition, etc.] should undergo regular screening mammography starting at age 45 years (strong recommendation).

Women aged 45 to 54 years should be screened annually (qualified recommendation).

Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually (qualified recommendation).

Women should have the opportunity to begin annual screening between the ages of 40 and 44 years (qualified recommendation).

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).

The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation).

Nancy Keating, professor of health care policy at Harvard Medical School and a primary care doctor at Brigham and Women’s Hospital in Boston, co-wrote an editorial accompanying the new guidelines.

In an interview, Keating described the four most striking aspects of new recommendations:

1) the more conservative starting age for mammography (45 vs. 40 years), which brings the ACS recommendations closer to the guidelines from another important advisory group, the U.S. Preventive Services Task Force (USPSTF), which endorse biennial screening for women aged 50 to 74 years;

2) the proposal for more frequent (annual) screening intervals among women aged 45 to 54 years;

3) the recommendation against routine screening CBE, a marked deviation from prior ACS guidelines and a stronger statement than that of the USPSTF, which in 2009 concluded that the evidence was insufficient to recommend for or against CBE;

4) the recommendation to stop screening among women with a life expectancy of less than 10 years.

Keating said that for some women, the new guidelines should make things easier because both the cancer society and the federal preventative task force basically line up on guidance. The big disagreement, Keating said, is over what to do for women age 45-54.

“This exemplifies the uncertainties of evidence,” Keating said. “Two really smart groups of people looked at the evidence and came up with different conclusions.”

Specifically, the cancer society included in its analysis findings from a large, observational study of mammography. That study concluded that for premenopausal (but not postmenopausal) women, annual mammograms were associated with smaller tumors.

“Smaller tumors should be better,” Keating said, “but we don’t have long-term data from that population. So we don’t know for sure if this leads to better outcomes.”

The context of all this is a greater awareness of the harms of false positive mammograms and the the real harm of over-diagnosis, which basically is when you’re diagnosed with a cancer that would never become “clinically evident” in your lifetime except for the fact that you underwent screening. This over-diagnosis, of course, can lead to the real harm of treatment for a cancer that you may never have needed to deal with. Continue reading

Mammogram? 50 Years Of Data And Decision Aids To Help You Think Through

A mammogram image, with arrow in upper left pointing to cancer

A mammogram image, with arrow in upper left pointing to cancer

Any procedure that involves sandwiching your naked breast between hard glass plates is personal. Very. But it’s becoming ever more clear that getting a mammogram also holds an element of personal decision. Medical authorities put out broad guidelines, but then you and your doctor can customize them, based in part on your own breast cancer risk and preferences.

How? Before we get into that, a paper just out in the Journal of the American Medical Association takes a sweeping look at a half century of mammogram data, and offers this big picture: mammograms do save lives, “but those benefits are not enormous,” said Dr. Nancy Keating of Brigham and Women’s Hospital and Harvard Medical School, the paper’s co-author. While the potential harms — that a woman will undergo cancer treatment for a tumor that never would have actually harmed her — have tended to be underestimated.

Here, Dr. Keating lays out the mammogram numbers that I found most helpful:

“If we take 10,000 women who are at average risk at age 40, over the course of ten years about 190 will be diagnosed with breast cancer. Most of these women will do well and would have done well regardless of screening. About five of those 10,000 women will have their life saved by the mammogram. Another 30 of those women will die regardless of the mammogram because unforutunately some breast cancers are so aggressive that they’re destined to be deadly despite the mammogram.

So there is benefit, five out of 10,000 women have their lives saved, but there are also these harms. One harm is false positives and unnecessary biopsies,: Of 10,000 women, about 6,000 will have at least one false positive. At this point, I say to patients, ‘You should expect that you’ll have some false positives, and don’t worry when they call you back.’ The over-diagnosis harm, we estimate: about 36 of those 190 cancers that were diagnosed could be over-diagnosed, and so those women will be treated — because we can’t currently tell the difference between the cancers we need to worry about and those that might not be so concerning, so we treat them all the same. So those women are then subjected to the harms of treatment without gaining any benefits.

So how to customize? How do you help create your own risk-benefit analysis? I asked the Informed Medical Decisions Foundation for helpful tools, and they suggested three:

The National Cancer Institute’s Breast Cancer Risk Assessment Tool

Public Health Agency of Canada Mammography Decision Aid

Healthwise

And for a bit more background, Dr. Keating discussed mammogram issues with co-host Anthony Brooks on Radio Boston, including these highlights:

On the questions Dr. Keating sought to answer in her review: Continue reading