Summary of screening guidelines
Three US medical organizations recommend annual screening mammography beginning at the age of 40 years, including the American College of Radiology (ACR), the National Comprehensive Cancer Network (NCCN), and the Society of Breast Imaging (SBI); these organizations do not place an upper age limit on screening mammography. In a statement at the 2016 annual NCCN conference, Therese Bevers, MD, of the University of Texas MD Anderson Cancer Center, stated, “For NCCN, several factors were considered when recommending annual screening; there are fewer cancer deaths in the annually screened population than those undergoing biennial screening; and while there are fewer deaths from breast cancer averted for women in their 40s, life-years gained are significantly greater.”38 Debra Monticciolo, MD, FACR, chair of the ACR Commission on Breast Imaging, concurs with the NCCN recommendations and states, “The ACR has strongly reaffirmed that mammography screening saves lives; the new ACR guidelines show that if a woman wants to reduce, as much as possible, her risk of dying of breast cancer, she will choose yearly mammography starting at age 40; moving away from annual screening of women ages 40 and older puts women’s lives at risk.”39 The SBI Screening Leadership Group (Drs. Bonnie Joe, Elissa Price, and Brett Parkinson) released a recommendation for yearly mammography beginning at age 40 because this “has the greatest chance of saving lives, preserves access, and acknowledges the right of each woman to choose.”40
The American Academy of Family Practice (AAFP), the American Cancer Society (ACS), and the US Preventive Services Task Force (USPSTF) do not recommend annual screening mammography beginning at age 40. The USPSTF emphasizes the adverse consequences of screening mammography, including overdiagnosis and overtreatment, false-positive results, the potential for psychological harm, and false-negative results.41 Further, the USPSTF uses the number of women needed to screen to save one life as its metric and concludes that by this metric, there is moderate evidence that the net benefit (of annual mammography) is small for women 40 to 49 years of age, there is moderate certainty that the net benefit is moderate for biennial screening mammography in women 50 to 74 years of age, and evidence is lacking and the balance of benefits and harms cannot be determined in women 75 years of age and older.41 Screening recommendations from the AAFP are similar to those of the USPSTF; in a recent summary of recommendations, it states that “the decision to start screening mammogram prior to the age of 50 is an individual one; if women place a higher value on the potential benefit than potential harms they may choose to begin biannual screening between the ages of 40 and 49.”42 Further, the AAFP posits that among women at average risk for breast cancer, most of the benefit of screening mammography is derived from biennial screening in women ages 50 to 74 years, and women ages 60 to 69 are the most likely to avoid breast cancer death because of screening mammography.42 The ACS released new mammography screening guidelines in October 2015; according to Chief Cancer Control Officer Dr. Richard Wender, a detailed review of evidence led the committee to change the guidelines after it had completed the difficult task of balancing the benefits and harms of screening mammography beginning at age 40.43 Dr. Wender states that “the new ACS guidelines make it clear that all women should begin screening by the age of 45 because that is when the benefits substantially outweigh the harms.”43
The American Congress of Obstetricians and Gynecologists (ACOG) released new breast cancer screening guidelines for women who are at average risk on June 22, 2017. Christopher M. Zahn, MD, ACOG Vice President of Practice Activities, stated that the new guidelines “consider each individual patient and her values, and because of the range of current mammography recommendations, the move has been made towards encouraging obstetrician-gynecologists to help their patients make personal screening choices from a range of reasonable options.”44 The new guidelines recommend that women past the age of 40 be offered screening mammography every 1 or 2 years, with the first screening mammogram occurring no later than age 50; in women beyond the age of 75, the decision to continue screening mammography should be made by each woman together with her provider and should be informed by the woman’s health status and longevity.44
As discussed, there is little consensus among the numerous medical organizations regarding mammography screening guidelines. The recommendations of seven US medical organizations are summarized in Table 1.
Scientific consensus regarding the expectations and limitations of mammography varies, and conflicting screening guidelines from medical organizations cause confusion for both patients and providers. Nevertheless, appropriate decisions regarding screening mammography should reflect an individual patient’s specific risk factors in conjunction with clinician judgment.
In an evaluation of the vast amount of data and numerous considerations regarding the cost and effectiveness of breast cancer screening, it becomes clear that the issues are difficult to reconcile adequately. However, two essential truths remain central to the discussion: (1) breast cancer is still the second leading cause of cancer death in women, and (2) mammography reduces breast cancer–specific mortality.
Karen Herold, DNP, WHCNP-BC, FNP-BC, Bram Goldstein, PhD, and January Lopez,MD, are affiliated with the Hoag Memorial Hospital Presbyterian in Newport Beach, California.
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- Independent UK Panel on Breast Cancer Screening. The benefits and harms of breast cancer screening: an independent review. Lancet. 2012;380(9855):1778-1786.
- Duffy SW, Tabar L, Chen HH, et al. The impact of organized mammography service screening on breast carcinoma mortality in seven Swedish counties. Cancer. 2002;95:458-469.
- Coldman A, Phillips N, Warren L, et al. Breast cancer mortality after screening mammography in British Columbia women. Int J Cancer. 2006;120:1076-1080.
- Hellquist BN, Duffy SW, Abdsaleh S, et al. Effectiveness of population-based service screening with mammography for women ages 40 to 49 years: evaluation of the Swedish Mammography Screening in Young Women (SCRY) cohort. Cancer. 2011;4:714-722.
- Moss SM, Cuckle H, Evans A, Johns L, Waller M, Bobrow L; Trial Management Group. Effect of mammographic screening from age 40 years on breast cancer mortality at 10 years’ follow-up: a randomized controlled trial. Lancet. 2006;368(9552):2053-2060.
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- Skaane P, Bandos AI, Gullien R, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology. 2013;267:47-56.
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- National Institute for Health and Clinical Excellence. Measuring effectiveness and cost effectiveness: the QALY. http://web.archive.org/web/20090809124835/http://www.nice.org.uk:80/newsroom/features/measuringeffectivenessandcosteffectivenesstheqaly.jsp (Accessed July 29, 2017).
- Puliti D, Duffy S, Miccinesi G, et al; EUROSCREEN Working Group. Overdiagnosis in mammographic screening for breast cancer in Europe: a literature review. J Med Screen. 2012;19(Suppl 1):42-56.
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- Breast Cancer Surveillance Consortium. Benchmarks for sensitivity and specificity for 2,061,691 screening mammography examinations from 2004-2008 – based on BCSC data through 2009. http://breastscreening.cancer.gov/statistics/benchmarks/screening/2009/table7.html (Accessed July 17, 2017).
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