USPSTF Makes Sweeping Changes to Breast Cancer Screening Recommendations

The U.S. Preventive Services Task Force, or USPSTF, has updated its recommendations for breast cancer screening with some significant changes, including a recommendation against routine screening mammography for women ages 40-49 who aren't at increased risk for breast cancer.

That change was made as a level C recommendation, which means that although the USPSTF 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 task force said in its explanation of the recommendation change that it encourages individualized, informed decision-making about when to start mammography screening and that the decision should take into account patient context, including the patient's values regarding benefits and harms.

Possible harms that can affect all age groups include false-positive test results, overdiagnosis and unnecessary earlier treatment, USPSTF members said. However, false-positive results are more common among women ages 40-49 than those in older age groups.

The USPSTF also recommended a switch from annual to biennial screening mammography in women ages 50-74, with the intent of reducing the potential harms of screening by nearly half. The task force's statement was published Nov. 17 in the Annals of Internal Medicine. The same issue includes a study that concluded that biennial screening intervals "are more efficient and provide a better balance of benefits and harms than annual intervals."

The task force said evidence that screening with film mammography reduces breast cancer mortality was greater for women ages 50-74 than those in the 40-49 age group, and the strongest evidence of benefit was seen among women 60-69.

The new recommendation statement is a significant shift from what the task force issued in 2002. At that time, the USPSTF recommended screening mammography, with or without clinical breast examination, every one to two years for women ages 40 and older.

In updating its recommendation, the USPSTF specifically assessed evidence on the efficacy of reducing mortality from breast cancer by screening with film mammography, clinical breast examination, breast self-examination, digital mammography and magnetic resonance imaging. To accomplish this task, the task force commissioned a targeted systematic evidence review of selected questions on benefits and harms of screening, as well as a decision analysis that used population modeling techniques to compare the expected health outcomes and resource requirements of starting and ending mammography screening at different ages and of using annual versus biennial screening intervals.

In another major change, the USPSTF now recommends against clinicians teaching women how to perform breast self-examination. In its 2002 recommendations, the task force had concluded that evidence was insufficient to recommend for or against teaching or performing self-examination.

The new recommendation says self-examination does not reduce mortality, but it is a level D recommendation, meaning the task force discourages the use of the service because there is moderate or high certainty that it has no net benefit or that the harms outweigh the benefits.

The task force also

Regarding the latter recommendation statement, the USPSTF said clinical breast examination lacks standards for approach and reporting.

"Clinicians who are committed to spending the time on CBE would benefit their patients by considering the evidence in favor of a structured, standardized examination," the task force said.

The AAFP's Commission on Health of the Public and Science is reviewing the evidence and recommendations for all of the task force recommendations regarding breast cancer screening.