ISSUE ADVISORY: American Cancer Society Lowers Recommended Age for Mammogram Screenings
By Danielle Lorizio, Government Relations Intern
Nov. 20, 2015
Breast Cancer Still a Leading Cause of Death – About 231,840 new cases of invasive breast cancer are estimated to occur in women this year and about 40,950 deaths from breast cancer will result, according to the American Cancer Society (ACS). Breast cancer remains the most common cancer among women in the U.S. – other than skin cancer – and breast cancer is the second leading cause of cancer death in women, after lung cancer. According to the U.S. Preventive Services Task Force, a federal research agency (USPSTF), the median age at diagnosis is 61 years and the median age at death is 68 years.
The Centers for Disease Control and Prevention (CDC) reported that from 2002 to 2011 in the U.S., the incidence rate of breast cancer remained level among all groups of women, except that it increased significantly by 0.7 percent per year among Black women and 0.8 percent per year among Asian/Pacific Islander women. But the good news is that deaths from breast cancer decreased at a statistically significant rate of 1.9 percent per year for all women, with a higher rate of reduction at 2.8 percent per year among American Indian/Alaska Native women.
Begin Screenings at Age 45 – In late October, the ACS released their new breast cancer screening guidelines, recommending that women at average risk of breast cancer begin yearly mammograms starting at age 45. Women 55 and older may get mammograms every other year and mammogram exams for women older than 74 is not recommended. Women who have concerns about the new guidelines should read the materials that are linked on the list at the end under Resources.
The ACS recommendation contrasts sharply from the U.S. Preventive Services Task Force’s recommendation, made in 2009, that women begin screening at age 50 and have a mammogram once every two years, not annually. At the time, USPSTF’s recommendation received criticism for having the potential to confuse women, dissuading them from getting necessary screening tests they may need at an earlier age. The USPSTF has recently solicited public comment on revisions to their breast cancer recommendations, but a final Recommendation Statement has not yet been released. The USPSTF’s recommendations are important because insurance companies generally tie their coverage policies to the task force’s recommendations.
For the USPSTF 2009 guidelines, a study in the Journal of the American Medical Association (JAMA) found that cancer statistics for U.S. women had not shown a reduced incidence of advanced breast cancers, despite widespread use of mammography. That finding is central to the cautionary note about the overuse of mammography as an unnecessary exposure to radiation. For the new ACS guidelines, an exhaustive review of the medical literature shows that frequent mammograms and manual breast checks by doctors are not very effective.
“The chance that you are going to find a cancer and save a life is very small,” according to Dr. Otis Brawley, chief medical officer for the American Cancer Society.
No More Manual Breast Exams – In addition, the American Cancer Society says that the clinical (manual) breast examination (CBE) by doctors can be skipped. The reason is that CBEs, along with mammography, increased the rate of false positives. The USPSTF recommended in 2009 that women not be taught to do manual breast self-examinations – something that had been strongly recommended in the past.
Several NOW activists, including women who have been treated for breast cancer, called and emailed the NOW National Action Center asking for our reaction about the ACS guidelines. The guidelines appear reasonable in that the American Cancer Society stresses that women must be aware of their family and personal medical histories and then decide when to begin and how often to have a mammogram, in consultation with their physician. There is no single year to begin exams or frequency of exams that could be cited as best for all women.
High Rate of False Positives – The ACS recommendation for women at average risk of breast cancer is to begin getting yearly mammograms at age 45 – which is five years later than the previous ACS recommendation to begin at age 40. This change follows from studies that have found that mammograms — still important in detecting early stages of breast cancer — have a relatively high rate of false positives. In other words, screenings can detect something suspicious that turns out be harmless. Australian researchers, for instance, have found that as many as a third of women diagnosed with breast cancer may not need treatment.
The aim of these updated guidelines is not to discourage women from getting mammograms. The ACS says that those who have a higher risk of breast cancer based on family history and personal medical history should get an MRI and mammogram every year. This includes women who have the BRCA 1 or BRCA 2 gene mutation, had radiation therapy to the chest between ages 10 and 30 or who have other syndromes associated with breast cancer.
The age guidelines that the ACS recommends are as follows:
These guidelines are for women at average risk for breast cancer. Women with a personal history of breast cancer, a family history of breast cancer, a genetic mutation known to increase risk of breast cancer (such as BRCA), and women who had radiation therapy to the chest before the age of 30 are at higher risk for breast cancer, not average-risk. (See below for guidelines for women at higher than average risk.)
Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so. The risks of screening as well as the potential benefits should be considered.
Women age 45 to 54 should get mammograms every year.
Women age 55 and older should switch to mammograms every 2 years, or have the choice to continue yearly screening.
Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer.
All women should be familiar with the known benefits, limitations, and potential harms associated with breast cancer screening. They should also be familiar with how their breasts normally look and feel and report any changes to a health care provider right away.
Criticisms of the ACS Guidelines – One criticism that was made of the studies evaluated by the ACS was that these were studies mostly of film mammography, which in the U.S. has been replaced by digital mammography. Digital mammograms, according to one source, produces clearer images, have lower false positive rates and are better at finding cancer. However, a 2005 study found that the two methods have similar accuracy in detecting cancer and that neither is better overall. Other critics said that the ACS looked only at whether screening was life-saving, not whether a cancer was caught early.
Similarly, the recommendation that doctors no longer conduct manual breast exams was criticized: the founder of the Feel Your Boobies Foundation, Leigh Hunt, notes this is a “free and easy way of knowing whether or not a lump is there.”
Current modes of detection are moving from over-reliance on mammograms as the tool for screening for breast cancer. With the increasing accuracy and popularity of alternative screenings, such as MRI or ultrasounds, mammography has been shown to be less effective. As noted, mammograms can increase the risk for over-diagnosing cancers, leading to invasive and painful treatments for cancers that would regress spontaneously if left alone and slow progressing cancers that pose minimal threat. Furthermore, annual mammography does not result in a reduction “in breast cancer specific mortality for women aged 40-59 beyond that of physical examination alone or usual care in the community,” a conclusion from the Canadian National Breast Screening Study.
ACOG Recommends Screening to Begin at Age 40 – The American College of Obstetricians and Gynecologists (ACOG) maintains its position on recommending annual mammography screenings at age 40 for women of average risk for breast cancer, developed in 2011 following a meta-analysis review of all research findings. In February, 2014, ACOG stated that a recent study published in the British Medical Journal (BMJ) prompted ACOG to look once again at their guidelines. The BMJ study included findings from the 30–year old Canadian trial which found that mammography screening did not result in a reduction of deaths from breast cancer. However, the ACOG statement pointed out that there have been eight other randomized clinical trials that have shown mammograms do help prevent deaths for women in their 40s and 50s. Also, numerous and more recent observational trials have confirmed reduced mortality with modern mammography screening methods.
Newer Technologies Improve Screening – As time goes on, science and technology evolve. Breast ultrasounds and thermography are methods for screening that unlike mammograms have no radiation exposure and are recommended for use in combination with mammography. Women with dense breast tissue, two-thirds of pre-menopausal women and one-quarter of post-menopausal women have less than a 48% chance of having breast cancer detected by a mammogram. Digital mammography was found in the 2005 study to be a better tool for women with very dense breast tissue, those who are under age 50 (regardless of breast density) or are pre-menopausal or peri-menopausal. Additionally, breast implants frequently interfere with cancer detection by mammography and additional methods of detection are needed.
Mammograms are a valued method of screening for breast cancer, as are ultrasounds, MRIs and thermography. Relying on the guidance of their doctors, women must have access to information that allows them to make the decision on what screening method is best for them. Guidelines from the American Cancer Society, the U.S. Preventive Services Task Force and from the American College of Obstetricians and Gynecologists are based on the best available evidence and are intended to inform doctors and women about the most effective measures they can take to detect breast cancer at its earliest stages. More detailed information is listed below.
American Cancer Society Recommendations for Early Breast Cancer Detection in Women Without Breast Symptoms,
Frequently Asked Questions About the American Cancer Society’s New Breast Cancer Screening Guide,
Draft Recommendation Statement – Breast Cancer Screening,
New Breast Cancer Guidelines: Screen Later, Less Often,
Final Recommendation Statement, Breast Cancer: Screening, November 2009,
A Systematic Assessment of Benefits and Risks to Guide Breast Cancer Screening Decisions,
Ob-Gyns Continue to Recommend Annual Mammograms for Women Beginning at Age 40, http://www.acog.org/About-ACOG/News-Room/News-Releases/2014/Ob-Gyns-Continue-to-Recommend-Annual-Mammograms-for-Women-Beginning-at-Age-40?p=1
Canadian National Breast Screening Study,
Breast Cancer Trends,
Should I Have A Mammogram? Breast Cancer Action,
Digital Mammography: Is Newer Always Better?,
Mammography v. Thermography,