a guest column by Peter R. Eby, MD, FSBI of Virginia Mason
posted 10 November 2015
This column is offered as a public service to Fremocentrist.com readers, for women and those who love them.
Controversy over when to start screening mammograms and how often to get them in average risk women has been around since the early 1990s. The American College of Radiology (ACR), United States Preventive Services Task Force (USPSTF) and American Cancer Society (ACS) all agree that screening every year starting at 40 will save the most lives. And yet, all three organizations have different recommendations for patients about mammograms.
The ACR, along with the National Comprehensive Cancer Network, American Congress of Obstetricians and Gynecologists, and American College of Surgeons recommend screening every year starting at age 40. The ACS recommends considering a mammogram between ages 40 to 44 then definitely getting one every year between ages 45 to 54, followed by continued screening every one to two years. The USPSTF draft for 2015 recommends starting at age 50, and getting a mammogram every other year. How can all these prestigious organizations, which are full of smart people, look at the same data and come to different conclusions? The issue boils down to one important question: should patients decide or should organizations decide for them?
While all agree that starting at age 40 and getting a mammogram every year saves the most lives, the reason why they disagree about when to start has to do with the relative value that each group places on the potential risks and costs associated with screening mammography. These include the money and time spent on the exam, the anxiety it may cause and the possible additional tests that the mammogram may generate when cancer is not present. Different patients often value each of the risks and benefits from a mammogram differently. Some are more anxious than others. Some have greater concerns about the expense of the exams. And some have a more pressing need to know the results.
The UPSTF and the ACS have tried to weigh the life-saving benefit of mammograms against the risks and choose what is best for all patients. Unfortunately, the USPSTF recommendations are tied to insurance coverage through the Affordable Care Act. For women between the ages of 40 to 49 years old the Task Force has assigned mammography a grade C. A grade C does not require insurance coverage. While the words of the USPTSF suggest the freedom of choice, their actions may require patients to pay the full cost of a mammogram from their own pocket. Those with limited incomes may have no choice at all.
The ACR, NCCN and others recognize that women at average risk for breast cancer have different values and support continued insurance coverage for patients to get a mammogram and exercise their right to choose for themselves. The opportunity should be offered every year beginning at age 40 because – as the ACR, ACS and USPSTF agree – that is the schedule that saves the most lives.
MORE INFORMATION:
The ACS says: “Screening mammography in women aged 40 to 69 years is associated with a reduction in breast cancer deaths across a range of study designs, and inferential evidence supports breast cancer screening for women 70 years and older who are in good health.” [Oeffinger KC et al. Breast Cancer Screening for Women at Average Risk 2015 Guideline Update From the American Cancer Society JAMA. 2015;314(15):1599-1614]
The USPSTF says: “The USPSTF found adequate evidence that mammography screening reduces breast cancer mortality in women ages 40 to 74 years.”
Questions and Answers
Q: When should I stop getting a mammogram?
A: There is no consensus on the answer to this question. The data on screening include women up to age 74 and show a benefit. Modeling studies show a benefit up to age 84. But the best answer may be related to a woman’s health. The goal of screening is to save lives. If a woman is in good health and has a life expectancy of 10 years, then screening can still be helpful and should be considered.
Q: What about high-risk women?
A: The recommendations are different for women with a lifetime risk of 20 percent or more (high risk). They include annual mammography, often starting earlier than age 40 and supplemented with MRI or other screening tests.
Fast facts about mammography
- In 2015 there will be:
- 231,840 cases of invasive cancer
- 60,290 cases of in situ breast cancer
- 40,290 deaths from breast cancer
- Early detection means lower stage, less chemotherapy and less cost of treatment.
- Breast cancer is the second leading cause of cancer death in the United States
- Breast cancer is the No. 1 cause of all deaths in women between the ages of 35 to 54
- One out of six breast cancers is diagnosed in women between the ages of 40 to 49
- 25 percent of all the years of life lost to breast cancer are women between ages 40 to 49
- Death rates from breast cancer in the United States have decreased 34 percent since mammography became widely used in the late 80s
- Seven out of eight women will not get breast cancer in their lifetimes
- African American women have earlier onset breast cancer and higher grade cancers that have more often spread to lymph nodes at presentation
- Compared to Caucasian women, African American women are 42 percent more likely to die from breast cancer in the United States [DeSantis CE Breast cancer statistics, 2015: convergence of incidence rates between black and white women. CA Cancer J Clin. 2015]
- Out of 1000 screening exams, 100 women will be recalled for additional imaging
- Out of 100 recalled patients, 19 will be recommended to have a biopsy
- Out of 19 biopsies, five women will be diagnosed with breast cancer
- Out of 1000 patients – 10 percent are recalled, 2 percent receive a biopsy recommendation and 0.5 percent receive a cancer diagnosis
Other sources of information
- Mammography Saves Lives website
- Downloadable .pdf of American College Of Radiology news release, Oct 20, 2015
- 12 Reason To Start Screenings At Age 40.pdf
Peter R. Eby, MD, FSBI, is section head of Breast Imaging in the Department of Radiology at Virginia Mason. He practices at Virginia Mason Hospital & Seattle Medical Center, Virginia Mason Kirkland Medical Center, Virginia Mason Issaquah Medical Center and Virginia Mason Federal Way Medical Center. Dr. Eby lives in West Seattle.
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Text ©2015 by Dr. Peter Eby
Images & Page ©2015 Kirby Lindsay.
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