When To Consider Stopping Screening
Clinical trial data for women aged 70 to 74 years are inconclusive. In its 2009 recommendation,11 the USPSTF extended the recommendation for screening mammography to age 74 years based on the extrapolation that much of the benefit seen in women aged 60 to 69 years should continue in this age range, and modeling done at the time supported this assumption. Current CISNET models suggest that women aged 70 to 74 years with moderate to severe comorbid conditions that negatively affect their life expectancy are unlikely to benefit from mammography.7, 8, 12 Moderate comorbid conditions include cardiovascular disease, paralysis, and diabetes. Severe comorbid conditions include AIDS, chronic obstructive pulmonary disease, liver disease, chronic renal failure, dementia, congestive heart failure, and combinations of moderate comorbid conditions, as well as myocardial infarction, ulcer, and rheumatologic disease.12
What Disconnect Have You Seen Between Oncologists Radiologists And The Task Force Guidelines
Many people make the analogy here with prostate cancer, and how recommendations with regard to prostate cancer have changed as we learn more about that disease.When you start getting disconnect like that, the answer is that both answers are likely correct. It is really a matter of timing when these organizations have their review cycles where they examine all of the data. I think thats where you start to see convergence, very much like we did this year with the USPSTF and the ACS kind of coming together. Still, there are some differences and slight quibbles in terms of interpretation, but I think youll see the same coming out of ACR and medical imaging societies, as well.
No matter which society you ask, I think all will agree that mammography is clearly important in terms of early detection of breast cancer. All will agree that there is slight harm associated with mammography, and its really kind of determining where that she sweet spot is, in terms of balancing risks and benefits. For women who are at average risk, these guidelines provide a framework for them to talk to their doctors about whats right for them, but they should continue to get mammograms on a regular basis as long as theyre healthy. That is really going to help, in terms of finding cancers early when they are the most treatable.
Screening For Breast Cancer
An Update for the U.S. Preventive Services Task Force
Heidi D. Nelson, MD, MPH Kari Tyne, MD Arpana Naik, MD Christina Bougatsos, BS Benjamin K. Chan, MS and Linda Humphrey, MD, MPH
Address correspondence to: Heidi D. Nelson, MD, MPH, Oregon Evidence-based Practice Center, Oregon Health & Science University, Mailcode BICC, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098 E-mail, .
The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.
This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
This article was first published in Annals of Internal Medicine in November 2009 . Select for copyright and source information.
Background: This systematic review is an update of evidence since the 2002 U.S. Preventive Services Task Force recommendation on breast cancer screening.
Study Selection: Randomized, controlled trials with breast cancer mortality outcomes for screening effectiveness, and studies of various designs and multiple data sources for harms.
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Why Are Breast Exams No Longer Recommended
Physicians should no longer routinely teach women aged 40-69 breast self examination as a screening technique for cancer because it can do more harm than good, the Canadian Task Force on Preventive Health Care has announced. The task force counsels healthcare providers on effective screening methods.
Benefits Of Detection And Early Intervention
There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women aged 50 to 74 years than for women aged 40 to 49 years. The strongest evidence for the greatest benefit is among women aged 60 to 69 years.
Among women 75 years or older, evidence of benefits of mammography is lacking.
Adequate evidence suggests that teaching BSE does not reduce breast cancer mortality.
The evidence for additional effects of CBE beyond mammography on breast cancer mortality is inadequate.
The evidence for benefits of digital mammography and MRI of the breast, as a substitute for film mammography, is also lacking.
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Role Of The Funding Source
This research was funded by the Agency for Healthcare Research and Quality under a contract to support the work of the USPSTF. The investigators worked with USPSTF members and AHRQ staff to develop and refine the scope, analytic framework, and key questions resolve issues during the project and finalize the report. AHRQ had no role in study selection, quality assessment, synthesis, or development of conclusions.
AHRQ provided project oversight reviewed the draft report and distributed the draft for peer review, including to representatives of professional societies and federal agencies. AHRQ performed a final review of the manuscript to ensure that the analysis met methodological standards. The investigators are solely responsible for the content and the decision to submit the manuscript for publication.
Observational studies of population-based mammography screening, limited by inherent biases of nonrandomized studies, reported a wide range of reductions in breast cancer mortality. Most studies were conducted in Europe or the United Kingdom and included women aged 50 to 69 years. Meta-analyses indicated a 25% reduction based on 7 incidence-based mortality studies and a 31% reduction based on 7 case-control studies. These results generally concur with our meta-analysis of trials for women aged 50 to 69 years that indicated a statistically significant 22% reduction.
Table 1 Pooled Rrs For Breast Cancer Mortality From Mammography Screening Trials For All Ages
Table 3 summarizes the evidence for this review. Breast cancer mortality benefits from RCTs of screening are based on estimates of women who were randomly assigned to screening, whereas harms are based on data from women actually screened.
Trials of mammography screening for women aged 39 to 49 years indicate a statistically significant 15% reduction in breast cancer mortality for women randomly assigned to screening versus those assigned to controls. This translates to a number needed to invite for screening to prevent 1 breast cancer death of 1904 . These results are similar to those for women aged 50 to 59 years but less than those for women aged 60 to 69 years. For women aged 70 years or older, results from the Swedish Two-County trial26 of women aged 70 to 74 years indicate no mortality reduction. However, these results are limited by including only a few women from 1 sample. Interpreting trial results stratified by age requires caution because except for the Age trial,29 age-specific results are subanalyses of trials designed for different purposes.
This document is in the public domain within the United States.
Requests for linking or to incorporate content in electronic resources should be sent via the USPSTF contact form.
Nelson HD, Tyne K, Naik A, Bougatsos B, Chan BK, Humphrey L. Screening for Breast Cancer: An Update for the U.S. Preventive Services Task Force. Ann Intern Med 2009 151:727-37.
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New Breast Cancer Screening Guidelines: Uspstf Says Mammograms Before Age 50 Aren’t Essential
Many clinicians and patients are frustrated and confused by the growing numbers of expert groups recommending women begin breast cancer screening later in life. This includes the U.S. Preventive Services Task Force , a panel of government-appointed independent physicians that draws up guidelines on preventative care and screenings.
On Monday, the panel published new guidelines in the Annals of Internal Medicine recommending biennial mammograms for women age 50 to 74 who have an average risk for breast cancer. The USPSTF guidelines suggest breast cancer screening with mammography before age 50 has limited benefits, and conclude that more research is needed to assess whether women 75 and older actually benefit from the test.
In 2009, mammography guidelines became a subject of contentious debate when the USPSTF updated its breast cancer screening recommendations to suggest women undergo mammograms beginning at age 50 rather than 40 , and to do so every other year instead of annually. Despite widespread criticism and a large body of research on the life-saving benefits of mammography in the past half-decade, the task force has not backed down on that stance.
Uspstf Guidelines May Use A Narrow Lens
The authors of the study believe that USPSTF breast cancer screening recommendations, may not be sensitive to racial differences and may be inappropriately extrapolating data from largely white populations for use in racially diverse populations. The concern here is that these guidelines may result in underscreening for nonwhite female patients, putting them at higher risk.
The study examined 747,000 breast cancer cases from 1973 to 2010, and found that nonwhite patients were more likely than white patients to be diagnosed with breast cancer younger than the age of 50. The authors of the study concluded, Current USPSTF breast cancer screening recommendations do not reflect age-specific patterns based on race.
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Accuracy Of Knowledge About Changes To Screening Guidelines
Women who reported being aware of the changes were asked to report what changes had been made. These responses were categorized. The percentage of respondents describing different types of changes are reported in Table . As can be seen in the table, for knowledge about changes to start age, 29.7% of respondents provided an accurate answer . For knowledge about changes to recommended frequency, 36.1% of respondents provided an accurate answer .
Table 4 Knowledge of changes to mammography recommendations
When accuracy for both frequency and age were considered together, only 11.9% of respondents reported correctly both age change and frequency change . We examined whether accuracy of knowledge was predicted by any demographic or personal experience variables. Accurate knowledge did not vary as a function of any demographic variable.
Final Uspstf Guidelines Scale Back Breast Cancer Screening
In Partnership With:
The US Preventive Services Task Force has issued final guidelines that stand by its recommendation that women at average risk of breast cancer should not start routine screenings until they reach age 50 years and that they should then undergo testing every 2 years.
Albert Siu, MD
The US Preventive Services Task Force is standing by its controversial recommendations on breast cancer screening in a final set of guidelines that call for an individualized approach to routine mammograms for asymptomatic women under age 50 years and biennial testing for women age 50 to 74 years.
The recommendations, which have been hotly debated for more than 5 years, recognize adequate evidence that mammography screening has reduced breast cancer mortality but said most of the benefit for women at average risk for breast cancer is derived by those age 50 to 74 years who undergo screening every 2 years.
The new guidelines were announced by the USPSTF and published simultaneously in the Annals of Internal Medicine,1 which also ran an editorial saying it was time to douse the firestorm concerning screening. Nevertheless, the immediate reaction in the oncology community suggested the debate would continue.
However, the American College of Radiology and the Society of Breast Imaging said in a joint statement that following the recommendations would result in lethal consequences for thousands of women each year.
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Where Can I Go To Get Screened
You can get screened for breast cancer at a clinic, hospital, or doctors office. If you want to be screened for breast cancer, call your doctors office. They can help you schedule an appointment.
Most health insurance plans are required to cover screening mammograms every one to two years for women beginning at age 40 with no out-of-pocket cost .
Are you worried about the cost? CDC offers free or low-cost mammograms. Find out if you qualify.
Give Your Opinion About The Uspstf Guidelines For Mammography Screenings Let Your Voice Be Heard
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Can I Ask For Ultrasound Instead Of Mammogram
A breast ultrasound isnt typically a screening tool for breast cancer. Instead, a physician might order an ultrasound, also called a sonogram, of the breasts if a screening mammogram produces unusual results. A physician might also use a breast ultrasound as a visual guide while performing a biopsy of the breasts.
Primary And Adjunctive Screening In Women With Dense Breasts
The USPSTF found insufficient evidence to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, MRI, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram.
Epidemiology of Dense Breasts
In the United States, the most commonly used classification system for breast density is the American College of Radiologys Breast Imaging Reporting and Data System 4-category scale . Data from the BCSC indicate that about 25 million women aged 40 to 74 years are classified as having heterogeneously or extremely dense breasts. The proportion of women with dense breasts is highest among those aged 40 to 49 years and decreases with age.14
Increased breast density is a risk factor for breast cancer. Data from the BCSC indicate that, compared with women with average breast density, women aged 40 to 49 years with heterogeneously or extremely dense breasts have a relative risk of 1.23 for developing invasive breast cancer. For women aged 50 to 64 years with heterogeneously or extremely dense breasts, the RR is 1.29, and for women aged 65 to 74 years, it is 1.30.7 However, women with dense breasts who develop breast cancer do not have an increased risk for dying from the disease, after adjustment for stage, treatment, method of detection, and other risk factors, according to data from the BCSC.15
Primary Screening Test Performance Characteristics
Primary Screening Frequency
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Primary Screening For Breast Cancer With Conventional Mammography
|Population||Women aged 40 to 49 y||Women aged 50 to 74 y||Women aged 75 y|
|The decision to start screening should be an individual one.Grade: C|
|Risk Assessment||These recommendations apply to asymptomatic women aged 40 y who do not have preexisting breast cancer or a previously diagnosed high-risk breast lesion and who are not at high risk for breast cancer because of a known underlying genetic mutation or a history of chest radiation at a young age. Increasing age is the most important risk factor for most women.|
|Screening Tests||Conventional digital mammography has essentially replaced film mammography as the primary method for breast cancer screening in the United States. Conventional digital screening mammography has about the same diagnostic accuracy as film overall, although digital screening seems to have comparatively higher sensitivity but the same or lower specificity in women age < 50 y.|
|Starting and Stopping Ages||For women who are at average risk for breast cancer, most of the benefit of mammography results from biennial screening during ages 50 to 74 y. While screening mammography in women aged 40 to 49 y may reduce the risk for breast cancer death, the number of deaths averted is smaller than that in older women and the number of false-positive results and unnecessary biopsies is larger. The balance of benefits and harms is likely to improve as women move from their early to late 40s.|
Mayo Clinic Response To Uspstf Breast Cancer Screening Statement
In its newly-announced breast cancer screening recommendations, the U.S. Preventive Services Task Force says the decision to start mammography should be an individual one for women ages 40 to 49. Mayo Clinic agrees, but also recommends regular screening for a woman who says she’s unsure how to proceed.
“The guidelines are important, but just as important is that the patient has the opportunity to visit with their doctor and find out whats right for them. In essence, its an individualized, informed decision, says Sandhya Pruthi, M.D., consulting physician at Mayo’s Breast Diagnostic Clinic. “If youre in doubt, then having a mammogram annually is appropriate.”
Watch Dr. Pruthi here
The Task Force notes women in their forties have a lower incidence of breast cancer and denser breast tissue than older women, which can cause higher rates of false positive findings, and could lead to benign breast biopsies. Mayo Clinic acknowledges these factors, but believes the benefits of regular screening, including increased treatment options when breast cancer is detected early, outweigh the risks.
For women ages 50 to 74, the Task Force recommends screening every two years. Mayo Clinic recommends individualized decisions, but that the default schedule be for annual screening, so as to favor the survival benefit.
Journalists: Sound bites from Dr. Sandhya Pruthi are available in the downloads below.
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