Breast cancer is the second-leading cause of cancer death in the United States, and mammography is a critical tool for detecting the disease.
That's why the U.S. Preventive Services Task Force (USPSTF) reassessed the evidence on breast cancer screening for its latest draft recommendation,(screeningforbreastcancer.org) released April 21.
Based on this evidence, the USPSTF reaffirmed its 2009 recommendation to use mammography to screen women ages 50-74 for breast cancer every two years (B recommendation).(www.uspreventiveservicestaskforce.org) But for women 40-49, the task force continues to recommend an individualized decision to screen, weighing the benefits and harms of screening every two years (C recommendation).
The USPSTF also concluded that there is insufficient evidence to recommend for or against screening women 75 or older (I recommendation).
- The latest draft recommendation on breast cancer screening from the U.S. Preventive Services Task Force (USPSTF) recommends mammograms every two years for women ages 50-74 but says the decision should be individualized for women ages 40-49.
- The USPSTF found insufficient evidence to recommend for or against screening women 75 or older.
- These USPSTF draft recommendations are open for public comment through May 18.
New since 2009, the USPSTF decided that evidence was insufficient to determine the effectiveness of three-dimensional (3D) mammography screening for detecting breast cancer and also insufficient for additional screening for breast cancer in women with dense breasts using ultrasonography, MRI, 3D mammography or other methods after they received a negative mammogram (I recommendations).
This draft recommendation updates the UPSTF's 2009 recommendation by clarifying its C recommendation for women ages 40-49. The draft statement(www.uspreventiveservicestaskforce.org) explains that a C recommendation for this age group isn't a recommendation against mammography but instead means the USPSTF sees only a small net benefit for the population, and women in this age group should individually weigh the benefits and harms of screening.
"Mammography is an important tool in reducing the number of breast cancer deaths. Based on the evidence, the Task Force found that screening is most beneficial for women ages 50 to 74," said USPSTF Immediate Past Chair Michael LeFevre, M.D., M.S.P.H., in a news release.(www.uspreventiveservicestaskforce.org) "The evidence shows that screening women ages 40 to 49 is beneficial, as well, but fewer women will avoid a breast cancer death by screening at this age. The number of women who experience a false-positive result and unnecessary testing is actually higher. Women who place a higher value on the potential benefit than the potential harms may choose to begin screening between the ages of 40 and 49.”
The USPSTF did not update its recommendation on the additional benefits and harms of digital mammography or MRI versus film mammography for breast cancer screening in women at average risk. Instead, the task force evaluated the effectiveness of an emerging technology -- tomosynthesis -- as a primary screening strategy and found insufficient evidence to recommend for or against its use (I recommendation).
The USPSTF also didn't change its recommendation against clinicians teaching breast self-examination to patients (D recommendation); however, the task force restated that it's important for women to tell their physician about lumps or other significant changes in their breasts.
In 2009, the AAFP agreed with the USPSTF's evidence-based guidance repeated in its own recommendations.
Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, told AAFP News that the division's subcommittee on clinical preventive services will now review this updated draft recommendation, including its evidence report,(www.uspreventiveservicestaskforce.org) and will report back to the USPSTF with its comments and/or concerns.
"Because the draft recommendation may change based on public comment, a final decision whether or not to endorse it is not made until the final recommendation is released," she said.
Concerns About the Recommendation
Before 2009, the USPSTF recommended mammography every one to two years starting at age 40. So, when the 2009 recommendation came out focusing on screening women ages 50-74, there was some concern that it could lead to missed screening opportunities and subsequent breast cancer deaths.
"While saving any life is important, there are much fewer lives saved in this age group (40-49)," Frost said. "And the risks are not small. The cancers detected may be slow-growing cancers that would not have affected the woman in her lifetime. This diagnosis of 'cancer' then potentially results in biopsies, major surgery, radiation and/or chemotherapy."
She also pointed out that "acceptable harms" can be subjective. "There are many who believe the risk of false-positives, invasive tests and potential surgeries are acceptable risks if the result is a life saved," Frost said. "Therefore, it's important to discuss these issues with our patients to determine what the best screening option is for them."
Frost noted that other organizations, such as the American Congress of Obstetricians and Gynecologists, the American Cancer Society and the American College of Radiology, continue to recommend annual breast cancer screening starting at age 40.
An additional concern with the C recommendation for women ages 40-49 has been that insurers might not cover mammography for this group.
"This was also a concern when the 2009 recommendation came out, but this did not occur," she said. "There is additional concern this time around as the USPSTF recommendations have a stronger link to payment. Under the (Patient Protection and) Affordable Care Act, insurers must cover all 'A' and 'B' recommended screening tests without a copayment. This does not mean, however, that they cannot cover 'C' recommendations."
High Risk Versus Average Risk
This updated recommendation also notes that women ages 40-49 with a first-degree relative (parent, sibling or child) who has had breast cancer may potentially benefit more than do average-risk women in this age group from beginning screening mammography before age 50. These women have a higher risk for breast cancer.
"The USPSTF recommendations are for women at average risk," Frost said. "They are not for women at highest risk, such as those with BRCA1 or BRCA2 gene mutation or other hereditary genetic syndromes or with a history of high-dose radiation therapy to the chest at a young age, such as for treatment of Hodgkin lymphoma."
With actresses Angelina Jolie and Rita Wilson speaking publicly about breast cancer and their mastectomies recently, patients might be more inclined to visit their physician's office for breast cancer screening.
But Frost said it is important to explain to concerned patients who are of average risk of breast cancer that these women were at high risk of breast cancer. For example, Jolie revealed in 2013 that she had tested positive for a mutation of the BRCA1 gene.
"Women with BRCA mutation are at greater risk and are not included under this recommendation," Frost said. "The USPSTF has a recommendation statement specific to BRCA screening."(www.uspreventiveservicestaskforce.org)
The USPSTF draft recommendations are open to the public for comment(screeningforbreastcancer.org) through May 18. The AAFP will submit its comments on the recommendations during this time.
Related AAFP News Coverage
USPSTF Draft Recommendation
Women at Risk for Breast Cancer Should Participate in Decisions About Risk-reducing Drugs