Anees B. Chagpar, MD
The controversial final set of guidelines recommended by the US Preventive Services Task Force (USPSTF) recognize “adequate evidence” that mammography screening has reduced breast cancer mortality, but maintain that most of the benefit for women at average risk for breast cancer is derived by those aged 50 to 74 years who undergo screening every 2 years.
The Task Force calls for an individualized approach to routine mammograms for asymptomatic women under aged 50 years and biennial testing for women age 50 to 74 years.
Though the issue has been debated for more than 5 years, since the Task Force drafted similar recommendations in 2009, agencies such as the American College of Radiology (ACR) and the Society of Breast Imaging said in a joint statement that following the recommendations would result in lethal consequences for thousands of women each year.
However, some medical experts say that while mammography early detection of breast cancer, biennial screening is sufficient.
In an interview with OncLive
, Anees B. Chagpar, MD, associate professor of Surgery (Oncology) and director of The Breast Center at Smilow Cancer Hospital at Yale-New Haven, shares her thoughts on the final guidelines and how they change the focus of screening.
OncLive: What are the key points of the final recommendation?
: What is being recommended is average-risk women from the age of 50 to 74 get screened every 2 years. For women between the ages of 40 and 50, they can kind of tailor that to their risk and discuss it with their doctor. In women 75 and older, there’s really more data that’s required. I think people may start to wonder how this varies with the the American Cancer Society (ACS) guidelines.
Now, the two organizations are really coming closer together. The ACS recommendations state that women aged 40 to 44 should really talk to their doctor and have individualized recommendations. Women who are 45 to 55 should get screened annually. In women 55 and older, there is evidence for screening every 2 years. Women who have a life expectancy of less than 10 years, or who are no longer healthy, should stop screening.
I think the main message you can take away from both sets of recommendations is that, for women who are, in the case of the USPSTF, over the age of 50 and, in the ACS, women who are over the age of 55, biennial screening is sufficient.
Both sets of recommendations are beginning to agree that, at some point, women need to start asking themselves whether they still need to be screened when they’re getting older and/or are less healthy.
For ages 50 to 74, biennial screening is a B recommendation. What message is that sending to the public?
If you look at national trends, and ask women, “Have you had a mammogram this year?” A lot of women forget. Therefore, if you get a mammogram every other year, that’s probably just fine. I think that’s the message that this is sending. It’s not sending the message—and I hope that it doesn’t send the message—that mammograms aren’t important. They still are. It’s the best technique for finding cancers early when they are the most treatable and the advent of screening mammography has truly been critical in the reduction in mortality that we’ve seen over the last several decades.
Does this raise the question that mammography is potentially harmful?
I don’t think that mammography is harmful. Both sets of guidelines make it very clear that there is an abundance of evidence that mammography saves lives. We know this. There have been at least 8 randomized controlled trials that have demonstrated that.
We know that, when we screen women, we can pick up cancers that can be potentially lethal. This is why mammography remains, really, a hallmark of early detection for breast cancer.
However, we are now seeing a balance of that benefit with other potential harms. Mammography does carry a slight risk and exposure to radiation. It does carry a risk of overdiagnosis. It does carry a risk of what we call false-positives, and the more we screen, the more we are going to find false-positives, and the more we are going to find cancers that would potentially never harm anybody. Of course, the more we screen, the more radiation we expose women to.
The question that I think both sets of guidelines are getting to is, “Where is the sweet spot? Where is the balance between the benefit that mammography clearly has, and the risks?”
What protocols should women with dense breasts follow for screening?
The issue with dense breast tissue is, on mammography, it looks white and cancers also look white. Therefore, women who have dense breasts often have what is called a false-negative. A small, white cancer may be hiding inside a white, dense breast so the mammography may be read as negative.