The AAFP has updated its recommendations for breast cancer screening based on evidence summarized by the U.S. Preventive Services Task Force, or USPSTF, which revised its recommendations in November.
The Academy's updated recommendations for breast cancer screening address various age ranges and screening modalities.
- The AAFP recommends that the decision to conduct screening mammography before age 50 should be individualized and take into account patient context, including the patient's risk factors, as well as her values regarding specific benefits and harms. That change was made as a level C recommendation, which means that although the AAFP recommends against routinely providing the service and there is at least moderate certainty that the net benefit is small, there may be considerations that support providing it in an individual patient.
- The AAFP recommends biennial screening mammography for women between ages 50 and 74.
- The AAFP recommends against clinicians teaching women breast self-examination.
- The AAFP concludes that the current evidence is insufficient to assess the benefits and harms of screening mammography in women ages 75 and older.
- The AAFP concludes that the current evidence is insufficient to assess the benefits and harms of clinical breast examination for women ages 40 and older.
- The AAFP concludes that the current evidence is insufficient to assess benefits and harms of either digital mammography or MRI instead of film screen mammography as screening modalities for breast cancer.
In the wake of controversy created by the new USPSTF recommendations, which initially recommended "against routine screening mammography in women aged 40 to 49 years," the AAFP's updated recommendations (see sidebar below) stress that family physicians should discuss with all women the potential benefits and harms of screening tests and develop a plan for early detection that minimizes potential harms.
These discussions, the Academy's recommendations add, should include information about the evidence regarding each type of screening test, the risk of breast cancer and individual patient preferences.
"What we feel is important, especially between the ages of 40 and 50, is that there should be a conversation between the patient and her physician," AAFP President Lori Heim, M.D., of Vass, N.C., told AAFP News Now. "It's not about not doing something. The focus is about doing something, and the first thing to do is have a discussion. That discussion could drive further action."
To help family physicians tackle those discussions, the AAFP's Commission on Health of the Public and Science is developing evidenced-based educational materials for members that outline the potential harms and benefits of breast cancer screening.
The USPSTF came under scrutiny after releasing its initial recommendations, which included the task force's position against routine screening mammography for women ages 40-49 who aren't at increased risk for breast cancer. The hue and cry that greeted that release culminated in task force members being called to testify at a Dec. 2 hearing by the Health Subcommittee of the House Energy and Commerce Committee.
Family physician Ned Calonge, M.D., M.P.H., chairman of the USPSTF, acknowledged during the hearing that portions of the recommendations were poorly phrased, and the task force voted unanimously on Dec. 4 to clarify its recommendations(www.uspreventiveservicestaskforce.org).
The revised USPSTF recommendations -- which were reviewed by the Academy's Commission on Health of the Public and Science -- call for biennial screening mammography for women ages 50-74 years and state that the decision to start regular, biennial screening mammography before the age of 50 should be an individual one that takes patient context into account, including the patient's values regarding specific benefits and harms.
According to Heim, family physicians are uniquely positioned to help women make decisions about screening, as well as about other aspects of health management.
"This really highlights what's so important about the relationship we have with patients," she said. "We have a powerful connection with them. It enables family physicians in particular to know the patient, know their history and help patients make decisions for themselves guided by a thoughtful discussion."