Albert Siu, MD
The US Preventive Services Task Force (USPSTF) is standing by its controversial recommendations on breast cancer screening in a final set of guidelines that call for an individualized approach to routine mammograms for asymptomatic women under age 50 years and biennial testing for women age 50 to 74 years.
The recommendations, which have been hotly debated for more than 5 years, recognize “adequate evidence” that mammography screening has reduced breast cancer mortality but said most of the benefit for women at average risk for breast cancer is derived by those age 50 to 74 years who undergo screening every 2 years.
The new guidelines were announced by the USPSTF and published simultaneously in the Annals of Internal Medicine
which also ran an editorial saying it was “time to douse the firestorm” concerning screening. Nevertheless, the immediate reaction in the oncology community suggested the debate would continue.
“Although for many years the dogma was that women should have mammograms ‘once a year for a lifetime’ starting at age 40 years, current evidence shows that the balance of risks and benefits of screening, particularly among women in their 40s, warrants more nuanced decision making,” Christine Laine, MD, MPH, the editor-in-chief of Annals of Internal Medicine
, and colleagues wrote in an editorial accompanying the guidelines article.2
“…The potential benefits of preventing breast cancer deaths are real, but the likelihood of those benefits is small and no definitive evidence shows that screening reduces total mortality.”
However, the American College of Radiology (ACR) and the Society of Breast Imaging (SBI) said in a joint statement that following the recommendations would result in lethal consequences for thousands of women each year.
“A recent study in the British Medical Journal
confirms that early detection of breast cancer via mammography is critical for improving breast cancer survival, regardless of therapy advances. Moving away from yearly screening in women 40-and-older endangers women, would cause needless death and disfigurement of women, and would simply not be good breast cancer screening policy,” said Debra Monticciolo, MD, FACR, chair of the ACR, in the joint statement.
Murray Rebner, MD, immediate past president of SBI, called the USPSTF’s guidelines “scientifically and methodologically flawed.” He said the group continues to recommend that women begin annual screenings starting at age 40.
Overall, the USPSTF guidelines apply to asymptomatic women who do not have preexisting breast cancer or a previously diagnosed high-risk lesion, or who are not at a higher risk level because of genetic mutations, a family history of the disease or a history of chest radiation at a young age.
The key recommendations, tailored to age levels, are these:
40-49 years: Recommends informed, individualized decision-making based on a woman’s values, preferences, and health history. (C recommendation)
50-74 years: Recommends mammography every 2 years. (B recommendation)
75 years and older: More research needed. Current science inadequate to recommend for or against. (I statement for insufficient evidence)
The US Department of Health and Human Services said the recommendations will not affect insurance coverage for mammography because of federal legislation signed in December 2015 that keeps benefits the same through 2017.
“Women 40 years and older enrolled in most health insurance plans will continue to be covered for screening mammography every 1 to 2 years without copays, coinsurance, or deductibles—just as they are today,” said Nancy C. Lee, MD, director, Office of Women’s Health at the US Department of Health and Human Services., in a statement. “If a woman is 40 years and older and her doctor determines that a mammogram is appropriate, she will not have to pay out of pocket.”
The debate over the recommendations would continue during the legislative protections, indicated William T. Thorwarth, Jr, MD, FACR, chief executive officer of the ACR. “This congressionally mandated delay will help providers continue to save tens of thousands of lives each year while the USPSTF recommendations and their creation process are vetted by breast cancer screening experts and lawmakers,” Thorwarth said in statement.
In expanding upon the USPSTF findings, Albert L. Siu, MD, MSPH, who chaired the panel, noted that the American Cancer Society (ACS) also has recognized that the benefits of mammography increase with age.