Breast Surgeons' Group Issues New Mammogram Guidelines
FRIDAY, May 3, 2019 (Pharmacist's Briefing) -- The largest organization representing U.S. breast surgeons is issuing new screening guidelines, advising women at average risk to begin annual mammograms at age 40.
Those guidelines differ from advisories from the influential U.S. Preventive Services Task Force (USPSTF), which moved first mammogram screening from 40 to 50 years of age, as well as that of the American Cancer Society, which puts the starting age at 45.
The American Society of Breast Surgeons (ASBrS) says it based the new guidelines on a different model than that used by the USPSTF.
The new guidelines recommend that all women undergo formal risk assessment by age 25. Screening based on specific risk factors is recommended for women with an increased risk of breast cancer.
Women with average risk should begin annual screening at age 40, however.
"Routine screening for women age 40 to 49 has been unequivocally demonstrated to reduce mortality by 15%," ASBrS president Dr. Walton Taylor said in a society news release.
"However, today's USPSTF guidelines delay annual screening until age 50 because they are based on an 'efficiency' statistical model that also considers the impact of potential screening risks," he said.
Risks or adverse effects in the USPSTF's calculations include the cost of screening, as well as the probability "of false-negative and -positive results," Taylor explained. Mistaken findings can mean unnecessary anxiety and unnecesssary medical procedures, he said.
In contrast, the new ASBrS guidelines "are based on a 'life-years gained' model," Dr. Julie Margenthaler said in the news release.
"They are based solely on the demonstrated breast cancer survival benefits. The ASBrS prioritizes life," said Margenthaler. She directs breast surgical services at the Siteman Cancer Center and is also professor of surgery at Washington University School of Medicine, both in St. Louis.
Individual risk assessment is a key part of the new guidelines, the ASBrS said.
For example, women with a predicted lifetime breast cancer risk of 20% or more should begin mammography screening, with access to supplemental MRI imaging, starting at age 35.
Similar imaging should start at age 25 for women with breast cancer-related genetic abnormalities, the group advised.
"While mammographic screening is not as easy or accurate in younger women, when we find and treat cancer, the benefits in years of life saved are highly significant. Many current guidelines will leave a subset of these women to die," Margenthaler explained.
Dr. Dana Smetherman is chair of the American College of Radiology (ACR) Commission on Breast Imaging. "Catching more cancers early by starting yearly screening at age 40 -- rather than less frequent or later screening -- increases the odds of successful treatment and can preserve quality of life for women," she said in the news release.
"We are pleased that ASBrS has reaffirmed their support for this most sensible approach," said Smetherman. The new ASBrS guidelines are in keeping with ACR recommendations.
Two more experts in breast cancer care supported the new guidelines.
"As breast surgeons we have long realized that one-size-fits-all screening is a problem," said Dr. Alice Police, regional director of breast surgery for Northwell Health Breast Care Centers of Westchester County in Sleepy Hollow, N.Y.
She believes that guidelines that don't account for individual risk profiles "sacrifice many 'life years' for some women for a greater good that claims to be more cost-effective and to create less anxiety."
Breast surgeons "think the life years are more important," Police said.
Dr. Kristin Byrne is chief of radiology at Lenox Hill Hospital in New York City. She believes the new guidelines are "individualized, in order to balance the benefits and harms of screening in each category without risking the patient's lives.
"For example, mammography should not be used on a patient under the age of 30 [under the ASBrS guideline]," Byrne noted. Instead, young, at-risk patients "with genetic mutations or prior chest wall radiation should have annual screening MRI until they feel it is safe for mammography screening," she said.
And at the other end of the life span, the new guidelines recommend stopping screening mammography when life expectancy is less than 10 years. This is "medically reasonable," Byrne said.
"Many guidelines have arbitrarily chosen the age of 74 to stop screening mammography, but this does not reflect the life expectancy of many individuals, and the risk of breast cancer increases with age," she said.
Finally, "screening every year for women of average risk over the age of 40 is essential to early diagnosis," Byrne believes.
The U.S. National Cancer Institute has more on mammograms.