The patient sitting on the exam table was happy to be diagnosed with breast cancer. That may seem unbelievable, especially for a 41 year old mother of young children. However, she was lucky to be screened. She is of the age where current controversy exists whether she should have an annual mammogram or not.
Fortunately, we followed the old guidelines which detected abnormal calcifications and she went for biopsy. The biopsy showed she had stage 0 breast cancer, completely curable (in her case with surgery alone). If new guidelines were followed and we waited to a later age to start screening, chances are her cancer would be untreatable and fatal.
The United States Preventive Services Task Force (USPSTF) is the agency that establishes guidelines for cancer screening and these guidelines are the one that the majority of US physicians follow. On December 4, 2009, the USPSTF changed its recommendations regarding breast cancer screening and now the advisement is to begin screening mammograms at the age of 50 years. Screening mammograms are suggested biennially between the ages of 50-74 years and states there is no evidence to continue screening mammograms at the age of 75 or older. Regarding women under the age of 50, the guidelines propose that the decision to do a screening mammogram should be done on an individual basis and the patient should be apprised of the risks and benefits. Additionally, the guidelines advise against teaching women to do breast self-exams (BSE). Although men can also get breast cancer, no guidelines exist for men at high risk.
Previous USPSTF guidelines recommended screening women 40 years and older every 1 to 2 years with mammography with or without BSE. These guidelines were the standard for doctors and patients for many years. However, since many insurers and the government tend to follow USPSTF guidelines, the shift to more conservative screening is evident. Despite this, many experts question the new guidelines as not enough to reduce breast cancer deaths and many doctors are sticking with the old guidelines.
The American Cancer Society (ACS) came out in opposite to the more relaxed guidelines of the USPSTF. However, they did revise their own guidelines.
Latest ACS Breast Cancer Screening Guidelines:
- Women at an average risk of breast cancer should begin annual mammograms at the age of 45.
- A woman can start screening at the age of 40 years if she chooses and discussion of mammograms between doctor and patient should start at that age.
- At the age of 55, mammograms should be biennial, unless a woman wishes to continue annual mammograms.
- As long as a woman is in good health, she should continue undergoing mammography.
- Breast exams are no longer recommended.
The American College of Obstetricians and Gynecologists (ACOG) offers another set of guidelines. They, in fact, decided to stay with the standard of performing screening mammograms starting at the age of 40 years. Additionally, they recommended continuing clinical breast exams as well as BSE. They cite experience as well as evidence should go in to determining screening guidelines. They fully support shared decision making between patients and physicians. Other specialty societies and government organizations like the CDC have their own set of guidelines.
Many question the rationale for the change in the guidelines. The USPSTF found evidence that, although mammogram reduced breast cancer mortality in women aged 40-49 years of age, this age group benefited the least. Women aged 60 to 69 years old tend to receive the greatest benefit from screening mammography, while those over 75 years have not demonstrated a clear benefit. Furthermore, they found data suggesting that women received more harm from screening mammograms than benefit. Harm entailed false positives resulting in over-diagnosis and over-treatment that would have otherwise not have been necessary. They also define a possible harm as anxiety that would have not been experienced if the mammogram had never been performed.
- There is a moderate certainty that screening mammogram in women aged 50-74 provides a moderate benefit.
- There is a moderate certainty that mammograms in women aged 40-49 does provide a small benefit but it is small.
- There is insufficient evidence of performing mammograms in women over the age of 75 years.
- There is insufficient evidence to perform clinical breast exams in women of any age.
- There is insufficient evidence of other screening modalities, such as MRIs.
When the USPSTF evaluated meta-analyses from clinical trials, it showed that 3 lives would be saved in women aged 40-49 for every 10,000 that underwent a mammogram. However, newer techniques are now available and it is likely that number is now higher.
According to the National Cancer Institute, of all women born in the US, 12.4% will develop breast cancer at some point during their lives. In women aged 40 years, 1.47% (or 1 out of every 68) will develop breast cancer before they turn 50. Another study tells us that breast cancer is the most common cancer type in the US and that one out of every four patients is afflicted with this disease before the age of 50. While the prognosis of breast cancer of those diagnosed before the age of 50 has been improving, these patients have increased mortality for decades after diagnosis. Additionally, data showed prognosis to be better among those patients diagnosed in their fifth decade of life. Breast cancer deaths have been decreasing since 1989 and the largest decrease was observed in women under the age of 50. This decrease is thought to be due to increased awareness, earlier detection through the screening, and improved treatment modalities.
While government agencies are tasked with balancing benefits and risks for the greater good, the fact is that breast cancer screening has resulted in earlier breast cancer detection and decreased mortality, across all ages. Although the USPSTF claims the harm of breast cancer screening outweighs the benefits, especially in women aged 40-49 years, one has to keep in mind the “harm” that is being weighed. Is a breast biopsy done of a breast lump that was detected on BSE a harm if it turns out negative? Or is it just a necessary test to diagnose a clinical abnormality? While a woman is exposed to radiation through mammograms, there has been no reported diseases or deaths resulting from performing a mammogram. A test that is negative does not become unnecessary after the results are in. Would a woman rather be found to be free of breast cancer? Or would she rather be diagnosed ten years after she develops the disease?
The government may be balancing millions of lives and three deaths among tens of thousands an acceptable rate, but in my practice I am responsible for every single life, one by one, that walks through my doors. As a family doctor with a special interest in women’s healthcare, I have diagnosed hundreds of cases of breast cancer. These patients come from all ages, all races and all socioeconomic statuses. My own experience is that I am now diagnosing more women at younger ages, in their 30s and 40s, for whatever reason. And if one of them has cancer, my job is to find it and get rid of it as soon as possible. As long as I continue to diagnosis breast cancer based on mammograms or breast exams, I will continue to do them. Yes, the guidelines look at evidence but they remain just that: guidelines. While the debate about mammograms rages on, women stand to die. We need clearer guidelines for both low and high risk women as well as men, who are also victims of breast cancer.
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About the Author
Linda Girgis MD, FAAFP is a family physician practicing in South River, New Jersey and Clinical Assistant Professor at Rutgers Robert Wood Johnson Medical School. She was voted one of the top 5 healthcare bloggers in 2016. Follow her on twitter @DrLindaMD.