Women are now advised to have a mammogram every second year from 40 until 74, according to new recommendations from the US Preventive Services Task Force, which says this is just as effective as annual screening.
The USPSTF, a volunteer panel of independent medical experts whose recommendations help guide doctors’ decisions and influence insurance plans, previously recommended that biennial mammograms start by 50 and that the decision for women to screen in their 40s “should be an individual one”, reports CNN.
These new recommendations, published in JAMA, replace the task force’s 2016 recommendations.
Some groups, likes the American Cancer Society, have already recommended women start mammograms in their 40s.
The updated recommendations do not apply to women with a personal history of breast cancer, a genetic marker or syndrome that may put them at a high risk of breast cancer, such as the BRCA1 or BRCA2 genes, or those with a history of high-dose radiation therapy to the chest or a history of a high-risk breast lesions.
Why not screen every year?
The USPSTF has received some criticism for recommending screening every other year, and not annually.
“Using USPSTF terminology, annual screening is just as ‘efficient’ as biennial screening but produces greater overall reductions in late-stage disease and deaths from breast cancer, and greater gains in years of life saved,” Dr Wendie Berg, of the University of Pittsburgh School of Medicine, wrote in an editorial in JAMA Oncology.
It was surprising, she said, that the USPSTF recommends biennial rather than annual screening.
“The updated USPSTF recommendations are an important step forward, but they stop short. Annual mammography is as efficient as biennial mammography but with greater overall gains in years of life saved,” she wrote.
“Annual screening is particularly important for premenopausal women, especially those in racial and ethnic minority groups.”
Along with recommending biennial screening, there are other concerns around how the USPSTF makes blanket recommendations for people at average risk as well as those with a family history of breast cancer or dense breasts, said Molly Guthrie, vice-president of policy and advocacy at the breast cancer foundation Susan G Komen.
About half of the women over 40 in the US have dense breast tissue, according to the US Food and Drug Administration, which last year updated mammography regulations to require that all US screening facilities notify patients about the density of their breasts with their mammography results.
“I fear that that’s going just to further muddy the water on what people are supposed to do,” said Guthrie.
Some experts say women with a direct family history of breast cancer or with dense breasts should have different screening recommendations, as both factors have been associated with an increased risk of developing breast cancer.
That’s why, Guthrie said, it’s best for women to talk to their doctors about theirb own personal medical and family history and what might be best for them individually.
In their review of published research and data, USPSTF members found no evidence to support screening annually, said said USPSTF Chair Dr Wanda Nicholson, a senior associate dean and professor at George Washington University’s Milken Institute School of Public Health.
“Currently there are no randomised trials comparing annual screening to every-other-year screening. However, as part of our systematic evidence review, which is part of all of our recommendation data, we did find evidence that if you compare screening every other year to annually, you do not have an increase in later-stage diagnosis of breast cancers.”
She said with annual screening, “you had a 50% higher rate of false positive results”.
The American Cancer Society recommends that women ages 40 to 44 have the option to screen with a mammogram every year, women 45 to 55 should get mammograms every year, and women 55 and older can switch to a schedule of mammograms every other year.
“The USPSTF decision today is a critical change concerning women’s health and the fight against breast cancer, acknowledging that women in their 40s will benefit from mammography screening, and sending a strong message to referring physicians and women that breast cancer screening should begin earlier than 50,” said Dr Karen Knudsen, chief executive officer at the American Cancer Society.
“However, we are disappointed that the updated USPSTF screening recommendations do not include women over 74, millions of whom are in very good health and are expected to live many more years during which their risk of breast cancer remains high.”
Updates
The updated recommendation includes both traditional digital mammography and digital breast tomosynthesis or “3D mammography” as effective screening approaches.
For the new recommendations, the USPSTF found “clear evidence” that showed the incidence of invasive breast cancers in women between 40 and 49 had been increasing by about 2% every year, Nicholson said.
“More and more women in their 40s were being diagnosed with invasive breast cancers,” she said. “And for the first time we also had data on black women, who are nearly 40% more likely to die from breast cancer than white women.”
The updated USPSTF recommendations note “pronounced inequities” in breast cancer, and that black women – compared with white women – are more likely to be diagnosed at advanced stages and to die, despite being less likely to be diagnosed with the disease overall.
The task force called for “rigorous research” to better understand these inequities and identify ways to address them.
“We need more studies on what’s the best interval screening for black women,” said Nicholson. “The current science shows they should start at age 40 and continue every other year to 74. But we need additional studies to look at whether there are different screening strategies that would be more helpful to black women.”
The revised USPSTF recommendations shed light on two major issues: addressing health inequities in breast cancer and ensuring all women can benefit from advances made in screening technologies, Dr Joann Elmore of the David Geffen School of Medicine at the University of California–Los Angeles, and Dr Christoph Lee of the University of Washington School of Medicine, wrote in a joint editorial in JAMA.
“Encouraging earlier screening starting represents just one facet of the breast care continuum. These assumptions include women accessing screening facilities with up-to-date technology, receiving prompt diagnostic evaluations, and accessing high-quality definitive treatment – a reality that does not always hold, particularly for women belonging to groups and communities that are traditionally underserved and under-resourced,” they wrote.
“Overall, the updated USPSTF recommendations highlight a rapidly evolving intersection of technology and equity within an already complex health care ecosystem in which disparities remain a persistent problem. It is important that physicians continue to …to ensure women make informed decisions aligned with their preferences.”
JAMA Oncology article – USPSTF Breast Cancer Screening Guidelines Do Not Go Far Enough (Open access)
Toward More Equitable Breast Cancer Outcomes (Open access)
See more from MedicalBrief archives:
Breast cancer screening from 40-74 – best US modelling study
Breast cancer screening does not reduce mortality
New breast cancer risks flagged by Washington researchers
Early mammograms increase radiation exposure, false readings – US study
False positive readings for 50% of 3D mammograms over a decade of screening