Ana Maria Lopez, MD
For women at average risk for breast cancer who are between the ages of 40 and 49 years, clinicians should have a personalized approach on whether their patients should be screened with mammography prior to the age of 50, according to a new evidence-based guidance statement issued by the American College of Physicians (ACP).1
Additionally, the guideline states that those who are at average risk for breast cancer and are between the ages of 50 and 74 with no symptoms of disease should be screened with mammography biennially.
The guidance statements do not apply to patients who have had prior abnormal screening results or in higher-risk patients. This includes patients with a personal history of breast cancer, or those who may harbor genetic mutations that are associated with increased risk, such as BRCA1/2
or another familial breast cancer syndrome.
“Beginning at age 40, average-risk women without symptoms should discuss with their physician the benefits, harms, and their personal preferences of breast cancer screening with mammography before the age of 50,” ACP president Ana María López, MD, medical oncologist, vice chair of medical oncology, chief of Cancer Services at the Sidney Kimmel Cancer Center, Jefferson Health, said in a press release.2
“The evidence shows that the best balance of benefits and harms for these women, which represents the great majority of women, is to undergo breast cancer screening with mammography every other year between the ages of 50 and 74.”
The ACP released two additional breast cancer screening guidance statements. For women who are at average risk for breast cancer and are ≥75 years, or in women who have a life expectancy of <10 years, breast cancer screening should be discontinued. Moreover, in average-risk women of all ages, a clinical breast examination should not be used as a method to screen for breast cancer, according to the guideline statement.
In average-risk women, the recommended breast cancer screening strategies vary; areas of uncertainty and lack of standardization have been the age to start and discontinue mammography, screening intervals, the role of imaging methods beyond mammography, and the role of clinical breast examination.
The ACP prepares and releases guidance statements that rely on evidence included in selected guidelines, as well as corresponding evidence reports. In this statement, the ACP reviewed guidelines from the American College of Radiology, American Cancer Society, American College of Obstetricians and Gynecologists, the Canadian Task Force on Preventive Health Care, the
National Comprehensive Cancer Network, the United States Preventative Services Task Force, and the World Health Organization. The Appraisal of Guidelines for Research and Evaluation II was used as a method to evaluate guidelines’ quality.
According to the guidance statement, it was determined that biennial mammography screening results in no significant difference in breast cancer mortality, though it considerably reduces screening harms when compared with annual mammography. Additionally, women who do have yearly mammograms receive more abnormal, false-positive results versus women who are screened biennially at 7.0% vs. 4.8%, respectively, which in turn lead to unnecessary biopsies and surgeries.
Approximately 20% of women diagnosed with breast cancer throughout a 10-year period will be overdiagnosed and likely overtreated.
Harms associated with breast cancer screening include overdiagnosis; false-positive results; overtreatment; radiation exposure, as well as radiation associated breast cancers and breast cancer deaths; and anxiety and distress from the corresponding tests and procedures, which include breast biopsies.
"The results of [ACP’s] assessment are 4 guidance statements that provide clarity and simplicity amidst the chaos of diverging guidelines,” Joann G. Elmore, MD, of David Geffen School of Medicine, University of California, Los Angeles, and Christoph I. Lee, MD, of University of Washington School of Medicine, wrote in an accompanying editorial.3
“These ACP guidance statements represent convergence across differing recommendations while highlighting important points for physicians to consider in shared decision-making conversations with their patients about routine breast cancer screening.”
- Qaseem A, Lin JS, Mustafa RA, et al. Screening for breast cancer in average-risk women: a guidance statement from the American College of Physicians [published online ahead of print April 9, 2019]. Ann Inter Med. https://bit.ly/2IlX8LR.
- ACP Issues Guidance Statement for Breast Cancer Screening of Average-Risk Women. American College of Physicians. Published April 8, 2019. https://bit.ly/2uR7yLn. Accessed April 8, 2019.
- Elmore JG, Lee CI. A guide to a guidance statement on screening guidelines [published online ahead of print April 9, 2019]. Ann Inter Med. https://bit.ly/2U4V6BT.