American Cancer Society aimed for clarity with revised breast
screening guidelines released last week, but Seattle-area
doctors and patient advocates worry that most women will still
be confused about their care.
average risk of breast cancer should start getting mammograms
at age 45, and get them annually until age 55, when they
should be screened every other year, the new guidelines say.
Plus, women can skip routine breast checks.
a change from the 2003 ACS advice, which recommended
mammograms every year starting at age 40, plus regular manual
exams by doctors.
closer to, but still different from, the U.S. Preventive
Services Task Force (USPSTF) recommendations that say most
women can wait until age 50 to start getting mammograms and
then get them every other year.
result? Many women still won’t know what to do, said Dr.
Joann G. Elmore, a University of Washington professor of
medicine and epidemiology who studies breast screening.
think the practical effect might be confusion," Elmore
said. "Women may be frustrated by the variability of
these back-and-forth guidelines."
about when and how often women should get mammograms have been
a hot debate for years, including the USPSTF guidelines used
as a basis for government health-insurance programs.
guidance likely won’t help, said Teri Pollastro, 55, a
patient advocate with Seattle’s Fred Hutchinson Cancer
Research Center who has been living with Stage 4 metastatic
breast cancer for years.
think it’s going to be more confusing, personally,"
Pollastro said. "My hope for these guidelines is that
they will spur a conversation between their primary care
doctor and the patient about what is the right age for me: Is
it 40 or 45?"
such conversations is the point of the new guidelines, which
were based on a rigorous, systematic review of evidence
published Tuesday in JAMA.
of researchers spent more than two years reviewing all
available data about breast cancer screening, said Ruth
Etzioni, a Fred Hutch biostatistician who helped draft the
study showed that regular screening exams in women aged 40 to
69 reduced the number of breast cancer deaths. The
recommendations aimed to balance the known benefits of
mammogram screening with potential risks and harms, including
problems with over-diagnosis and overtreatment, Etzioni said.
saying you don’t all have to run for mammograms at age 40,’"
Etzioni said. "It’s giving women more flexibility. In a
way, it’s saying, ‘Don’t panic.’"
230,000 women in the U.S. are diagnosed with breast cancer
each year, and more than 40,000 die, according to the ACS.
Deaths from breast cancer have declined steadily since about
1990, thanks to better detection and treatment, the study
defining when and how to screen women based on trustworthy
science has been difficult, Etzioni said. The new guidelines
attempt to reconcile what is known with what is not, she
really a new understanding of the limits of the
evidence," she said.
example, the evidence showed little benefit from clinical
breast examinations, the annual manual exams in which doctors
or other health providers feel a woman’s breasts to detect
palpable lumps or other problems.
recommendation that women at average risk skip such exams is
bound to be controversial, said Dr. Benjamin O. Anderson, a
University of Washington professor of surgery who directs the
Breast Health Clinic at the Seattle Cancer Care Alliance.
am actually disappointed in that," said Anderson, who is
also a Komen Scholar with Susan G. Komen, the national cancer
advocacy group. "The issue with clinical breast exam is
that it has not been studied in the same way."
he hoped doctors would continue the exams.
Seattle patient advocate who works with poor and minority
women says she worries that the new guidelines still don’t
adequately reflect the people she sees.
does not include the underserved population," said
Bridgette Hempstead, chief executive of Cierra Sisters, a
breast cancer support group for black women. "We will let
them know about the new national guidelines. But we will say,
€˜Now you need to have a very firm conversation with your
not clear what effect, if any, the new ACS guidelines will
have on insurance coverage of mammograms, Etzioni said. In the
U.S., the Affordable Care Act and some state laws require most
private health plans, Medicaid and Medicare to cover breast
editorial accompanying the JAMA report by Dr. Nancy L. Keating
of Harvard Medical School and Dr. Lydia Pace of Brigham and
Women’s Hospital in Boston emphasized that women need to
become informed consumers who weigh the risks and benefits of
screening in consultation with their health providers.
is important to remember and emphasize with average-risk women
older than 40 years that there is no single right answer to
the question: ‘Should I have a mammogram?’"
GUIDELINES FROM AMERICAN CANCER SOCIETY
Women should undergo regular mammography starting at age 45.
Women 45 to 54 years old should be screened annually.
Women 55 years and older should transition to screening every
other year, or have the opportunity to continue screening
Women should have the opportunity to begin annual screening
between the ages of 40 and 44.
Women should continue screening mammography as long as their
overall health is good and they have a life expectancy of 10
years or longer.
Clinical breast examination is not recommended for breast
cancer screening among average-risk women at any age.