By MELINDA BECK
In a recognition that breast cancer screening can bring both benefits and harms, the American Cancer Society issued new guidelines saying women should start have mammograms later and less often than it previously recommended. But the group also acknowledged that one recommendation doesn’t fit all.
The society’s new guidelines, issued Tuesday, strongly recommend that women start annual mammograms at 45—from its previous recommendation that they begin at 40.
At age 55, women should cut back to one mammogram every two years and continue that pattern for as long as they are healthy and expect to live at least 10 more years, the cancer society said. That is because breast cancer in that age group grows slowly enough that yearly screenings add only a small benefit while raising the risk of false positives.
However, the nonprofit group said, women who want to start screening at 40, or continue having annual mammograms after 55, should have the opportunity to do so.
The guidelines, published in the Journal of the American Medical Association, recommend against clinical breast exams—in which a physician manually checks for lumps—for women of any age. The intent is to signal that the exams aren’t a substitute for a mammogram, said Richard Wender, the group’s chief cancer control officer.
Dr. Wender said that while the society’s previous guidelines were simpler, they “left no room for understanding that [women’s] risk changes as they age or that some women may value the benefits and harms differently.”
The new guidelines, which apply to women at average risk, are closer to the U.S. Preventive Services Task Force’s 2009 recommendation that women wait until 50 and have mammograms only every other year. That guidance sparked controversy, with some women complaining it suggested health-care rationing. Amid the concern, Congress added an exception to the Affordable Care Act requiring insurers to cover annual mammograms starting at age 40 at no cost.
Now the task force is also revising its guidelines. A draft version issued in April recommended biennial screening for women ages 50 to 74, but said that women who place a higher value on the potential benefits than the potential harms of mammograms may choose to begin biennial screening between 40 and 49.
Kristen Bibbins-Domingo, the task force’s co-vice chairman, said it would issue final recommendation after considering many public comments and that it was up to lawmakers and insurers to determine coverage decisions.
The idea that cancer screening could be harmful is hotly debated. Awareness campaigns have long stressed that early detection saves lives. Thanks to widespread mammography, the vast majority of the approximately 230,000 breast cancers diagnosed annually in the U.S. are now found at early stages, when the chance of survival exceeds 90%.
Studies have estimated that annual screening can cut the risk of death by 15% to as much as 40%. But mammograms frequently raise false alarms. One large study found that 61% of women who have annual mammograms for 10 years will be called back at least once for additional imaging that finds nothing amiss, and 7% to 9% will have biopsies that don’t find cancer.
Moreover, studies suggest that 5% to 50% of women are treated for early-stage breast cancer that would never cause harm.
Several organizations, including the American College of Radiology and the Society of Breast Imaging, issued statements reiterating their support of annual mammograms starting at 40.
Susan G. Komen, a nonprofit advocacy group, called for women, regardless of age, to have access to regular mammograms when they and their doctors think it is appropriate. Judy Salerno, the group’s president and chief executive, acknowledged that overdiagnosis is an issue, but said, “A woman cannot make a decision about treatment…if she hasn’t been screened.”
The cancer society’s Dr. Wender said the group evaluated evidence in five-year increments and concluded that between ages 40 and 45, a women’s risk of having breast cancer was closer to a 30-year-old’s than a 50-year-old’s. But by age 45, the risk was high enough that all women should undergo the screening.
The recommendation to switch to biennial mammograms after age 55 was based on an analysis, published simultaneously in JAMA Oncology, that found tumors discovered in postmenopausal women are likely to grow slowly enough that yearly screenings added only a small benefit while increasing the risk of false positives.
The society’s recommendation against clinical breast exams was more surprising, some experts said, since there are no trials assessing their effect on breast-cancer mortality. The society’s earlier recommendation called for such exams periodically for women in their 20s and 30s, and annually after age 40. Dr. Wender said the society meant to convey the message that a clinical breast exam “should not be a replacement for a mammogram, which offers the best chance of detecting cancer.”
Therese Bevers, medical director of the Cancer Prevention Center at M.D. Anderson Cancer Center, said she hoped women wouldn’t interpret that to mean they should get mammograms and skip seeing a doctor. “The clinical exam is where risk assessment is performed, and where women are counseled to lose weight and make other changes that we know can reduce the risk of breast cancer,” she said.
“That is going to drive people wild—all of us have picked up [tissue] masses in clinical exams,” said Mary Jane Minkin, a professor of obstetrics and gynecology at Yale School of Medicine. She also said that discussing the guidelines with older patients will be difficult: “It’s hard to say to a patient who is older, ‘I don’t think you’re going to be alive in 10 years.”
Laura Esserman, a breast surgeon at the University of California, San Francisco, said the debates underscore the need for more up-to-date data.
“Most of what we are arguing about is from trials conducted 30 years ago,” she said. She hopes to enroll 100,000 women in a five-year randomized-controlled trial, dubbed WISDOM, that will compare annual mammograms starting at 40 to screening at different intervals, and with different technologies, based on family history, genetic makeup, environmental exposures, breast density and other factors.
“We may need to screen some women more often and some women less often, based on their risk,” Dr. Esserman said. “But we’ll never settle without more data.”
See the original Wall Street Journal article here.