Women with an average risk for breast cancer should undergo regular screening mammography beginning at age 45 years, according to an updated guideline from the American Cancer Society published in JAMA.
Further, the guideline recommends women aged 40 to 45 years should have the opportunity to begin screening, and women should transition to biennial screening at age 55 years with the option to continue annual screening.
Although the number of breast cancer deaths have been steadily declining for the past quarter century, it remains the second-leading cause of cancer death among women in the U.S. Approximately 230,000 women will be diagnosed with breast cancer and an estimated 40,300 women will die from the disease in 2015.
Robert A. Smith
“Prior to this update, our most recent guideline for breast cancer screening in average risk women was published in 2003,” Robert A. Smith, PhD, cancer epidemiologist and senior director of cancer control at ACS, as well as an adjunct professor of epidemiology at the Rollins School of Public Health at Emory University School of Medicine, told HemOnc Today.
That guideline recommended women undergo annual screening beginning at age 40 years.
“Since, 2003, a considerable volume of new data has emerged, including both updates of the randomized trial data, but especially observational studies of population-based organized screening and modeling studies,” Smith said. “There also is more emphasis on considering not only the benefits of screening, but also the downsides, considering each in making recommendations, and allowing for individual values and preferences in some of the decisions adults make about screening when the balance of benefits to harms is less certain.”
The guidelines are intended for women with an average breast cancer risk, or women without a personal history of the disease, a suspected or confirmed genetic mutation known to increase breast cancer risk, or a history of chest radiotherapy at a young age.
The ACS strongly recommended — which indicates that the benefits outweigh the harms that could result from screening — regular screening for women with an average risk for breast cancer beginning at age 45 years. The guidelines offered a qualified recommendation —indicating that there is a clear evidence of benefit, but less certainty about the balance of benefit and harm, or a patient’s values and preferences — that screening in women aged 45 years should occur annually.
The ACS also offered qualified recommendations that:
- Women aged 55 years and older should switch to biennial screening but have the opportunity to continue annual screening if they so choose;
- Women aged 40 to 44 years should have the opportunity for annual screening;
- Mammography screening should continue for women as long as they are in good health or have a life expectancy of at least 10 years; and,
- Clinical breast examinations for breast cancer are not recommended for average-risk woman of any age.
“Some aspects of our guideline have changed, but each recommendation either has been reinforced or modified due to the data that have accumulated in the last decade,” Smith said. “In every respect, this new guideline is grounded in the evidence, including those periods in the early 40s and after age 55 years when women have options based on their values and preferences. We think this is an important feature.”
Decision to screen
In an accompanying editorial, Nancy L. Keating, MD, MPH, professor of health care policy and medicine at Harvard Medical School and a physician at Brigham and Women’s Hospital, and Lydia E. Pace, MD, MPH, a physician specializing in women’s health and internal medicine at Brigham and Women’s Hospital, questioned whether these new guidelines will simplify screening decisions for women and their clinicians.
Nancy L. Keating
“In some ways, the messages from ACS and the U.S. Preventive Services Task Force [USPSTF] — two major guidelines — are now more consistent,” they wrote. “Both guidelines agree that for average-risk women younger than 45 years, the harms of mammography screening likely outweigh the benefits. The new ACS recommendation to stop screening older women with life expectancies of less than 10 years is practical and consistent with the increasing emphasis on functional vs. chronological age.”
However, Keating and Pace pointed out there is still discordance between the ACS and USPSTF recommendations for women ages 45 to 54 years.
“ACS recommends annual screening but … the USPSTF recommends no routine screening (ages 45-49 years) or biennial screening (age 50-54 years),” they wrote. “In communicating with patients, clinicians will have to balance the ACS’ recommendation for more frequent screening against the fact that younger women experience a lower absolute benefit from screening mammography.” – by Anthony SanFilippo
Disclosure: Smith reports no relevant financial disclosures. Please see the full study for a list of all other researchers’ relevant financial disclosures. Keating reports serving as medical editor for the Informed Medical Decisions Foundation, part of the nonprofit Healthwise. Pace reports no relevant financial disclosures.