New mammography screening guidelines issued April 3 by the American College of Physicians (ACP) suggest that women age 40 to 49 should work closely with their physicians in determining whether yearly mammograms are necessary.
Despite the new guidelines, Susan G. Komen for the Cure remains firm in their recommendations that women in the 40 to 49 year age group continue to undergo yearly screening mammograms to reduce their risk of dying of breast cancer.
"Komen for the Cure feels that the modest survival benefits of mammography in this age group outweigh the risks of false positive results, and they recommend regular mammograms for women ages 40 to 49," said Cheryl Perkins, M.D., senior clinical advisor for Susan G. Komen for the Cure.
The ACP guidelines and accompanying article, published in The Annals of Internal Medicine, were developed to present the evidence and to increase understanding of the risks and benefits of screening mammography by clinicians.
The ACP recommendations include:
1. Clinicians should periodically perform individualized assessment of risk for breast cancer in women age 40 to 49 to help guide decisions about screening mammography.
2. Clinicians should inform women 40 to 49 years of age about the potential benefits and harms of screening mammography.
3. Clinicians should base screening mammography decisions for women 40 to 49 on benefits and harms of screening, as well as on a woman's preferences and breast cancer risk profile.
4. The ACP recommends further research on the net benefits and harms of breast cancer screening modalities for women 40 to 49 years of age. (1)
ACP discussion of recommendations included the following points
1. There is a wide variability in the 5-year risk of breast cancer in the 40 to 49 years of age group. Because risk factors can change, regular updates of risk were suggested, especially in those with changes in their family history and who don't have regular screening mammograms. Additionally, the commonly used Gail risk model is good for predicting risk for groups, but is not good for determining individual risk.
2. The most important benefit of screening mammography is a reduction in death from breast cancer. The conclusion of this report was that "evidence demonstrates that screening mammography in women age 40-49 years, compared with women who do not get screened, decreases breast cancer mortality." This reduction was less that that seen in women older than 49 years of age. One analysis reported that women aged 40 to 49 who get screening mammograms every 1 to 2 years can lower their risk of dying from breast cancer by 15 to 20 percent.
Screening mammography, the researchers indicated, is not without its downsides and risks. Such risks can include false positive findings, or findings on mammograms that might be cancer, but often require more tests and possibly a biopsy to determine for sure if it is cancer. Suspicious findings on a mammogram, even if they prove to be false positives for breast cancer, cause patients unnecessary anxiety. False positive mammograms can result from a patient's having dense breasts, a fairly common characteristic among women in the 40- to 49- year age group. Long intervals between screening mammograms and prior biopsies can also impact the results of screening mammograms.
Additional risks associated with screening mammography also include a false sense of reassurance when the findings on mammography are negative, discomfort or pain associated with the procedure which varied widely and was not reported to be a reason why patients would not have mammograms; an increased diagnosis of ductal carcinoma in situ (DCIS), or cancer that is contained within the ducts of the breast, which can result in treatment and surgery for many patients when it is not clear which cases will develop into invasive cancer. Currently, the outcome of DCIS cannot be reliably predicted.
Many people believe radiation exposure from mammograms presents a risk; however, no direct evidence links cancer risk with radiation exposure from mammography, according to the report. (1)
Susan G. Komen for the Cure Perspective
The study made some valid points about the need for ongoing risk evaluation and for being an informed provider and patient so the best, most individualized decisions can be made. However, there is a concern that the guidelines could cause confusion for women about the value of annual mammograms. Randomized controlled trials have shown that women 40 to 49 who get regular mammograms can lower their risk of dying from breast cancer by 15 to 20 percent, compared to the 25 to 30 percent lower risk seen in women ages 50 to 69. (2)
Compliance with screening guidelines is also a concern. Women between the ages of 40 to 49 are typically busy, have jobs and children and often find it difficult to do everything they have planned. Even now, when most groups recommend screening mammograms every 1 to 2 years for women in this age group, not everyone complies. Recent reports tell us that women in this group are having fewer screening mammograms and that even breast cancer survivors in this age group don't always continue to receive follow-up screening. The perception might be that breast cancer in this group is not as much of a risk and therefore, screening is less important.
Exercising personal choice should stem from an informed decision. Health care providers are busy, and there might not be time to discuss the risks and benefits and choices thoroughly enough with patients to allow them to make informed choices about the screening process. All women are at risk for developing breast cancer.
Risk evaluation tools cannot tell individuals that they will or will not develop breast cancer. At best, they help to determine the degree of risk. This helps to plan screening schedules and risk reduction plans. About five to ten percent of breast cancers are due to hereditary factors. The accuracy of using risk evaluations and personal preferences to plan a screening schedule for individuals is not reliable enough to forgo current recommendations. Most women with breast cancer have no known significant family history or other known risk factors aside from being female. (3)
As with all individual decisions, women should discuss their concerns, risks, plans, and then make decisions with the help of their provider to understand what is best for them.
The fact is that regular mammograms in this age group save lives. Susan G. Komen for the Cure continues to recommend annual screening mammograms for women of average risk in this age group.
Sources:
1. Qaseem, Amir, MD, et al,
Article: Screening Mammography for Women 40 to 49 Years of Age:
A Clinical Practice Guideline from the American College of Physicians,
Editorial: Breast Cancer Screening for Women in Their 40s: Moving from Controversy about Data to Helping Individual Women.
Summaries for Patients: Screening Mammography in Women Age 40 to 49 Years
Annals of Internal Medicine, Vol.146, 2007; pp 511-515, 516-526, 529-532.
2. Susan G. Komen for the Cure, About Breast Cancer,
Mammography
Mammography Recommendations
Accuracy of Mammograms
Mammography Debate
Radiation Exposure
Risk Matrix
Breast Cancer Risk Factors
3. Breast Cancer Facts and Figures 2005-2006, American Cancer Society
