Now that the ACS has weighed in, how will that change practice?

The American Cancer Society came out with new recommendations for breast cancer screening, calling for annual mammograms beginning at age 45 for average-risk women — even though the U.S. Preventive Services Task Force has said it isn’t justified until age 50, while radiologists’ groups have stood firm on age 40 as the time to start. The recommendations also differ in other respects.

We asked women’s health experts and a variety of healthcare professionals:

What will you tell women in their 40s who ask whether they should get annual mammograms?

How have patients been reacting to the previous controversies around mammography?

How much of a problem are these divergent recommendations, and what should be done about it?

The participants this week are:

Rachel Brem, MD, Vice Chair of Radiology and Director of the Breast Imaging and Intervention Center at the George Washington University School of Medicine and Health Sciences in Washington D.C.

Annina Wilkes, clinical assistant professor at the Sidney Kimmel Medical College at Thomas Jefferson University and Interim Director of Breast Imaging at the Jefferson Honickman Breast Imaging Center in Philadelphia

Kathryn A. Boling, MD, a primary care physician at Lutherville Personal Physicians, part of Mercy Medical Center, in Lutherville, Md.

Karen Oh, MD, associate professor within Diagnostic Radiology and Director of Breast Imaging and sub specialization in Obstetric and Gynecologic ultrasound at Oregon Health & Science University in Portland

Angela DeRosa, DO, MBA, clinical assistant professor at Midwestern University, Arizona College of Osteopathic Medicine, in Glendale and founder, DeRosa Medicine

No Change in Recommendations

Rachel Brem, MD: I will unequivocally recommend that women begin annual screening mammography at age 40 and continue annually thereafter. The new recommendations of the American Cancer Society (ACS) are a compromise between the benefits of screening mammography, lives saved, and the harms, which is the anxiety from mammography callbacks and the possibility of a biopsy for a benign finding. As a physician and a breast cancer survivor myself, the benefits clearly outweigh any “harms,” which are fleeting. My goal is to assure women the right to obtain screening mammograms to optimally diagnose early curable breast cancer. It is also important that women understand that the new ACS recommendations are a compromise. The ACS recommends that women continue to have the opportunity to decide to have screening mammograms beginning at 40 and annually thereafter.

Annika Wilkes, MD: In our practice we will continue to recommend annual mammography beginning at age 40. We will tell our patients that we will continue our recommendation because while it is a good idea to discuss personal risk factors for breast cancer and family history with their doctors, it should not change the interval of screening. Most women who develop breast cancer have no risk factors at all and annual mammography is the best way to catch a cancer when it is at its earliest, most treatable stage. We certainly agree that women should be familiar with the limitations of mammography including the potential need to be called back for additional views, possible short interval follow-up, and biopsy. These so called ” harms” do not occur for most patients. I would doubt that these factors would deter a patient from the possibility of early detection.

Dealing with Different Guidelines

Kathryn Boling, MD: I discuss with patients the fact that there are differing recommendations regarding when to start mammogram screening and how often to have screening. I do discuss with patients the risk of false positive results and attendant testing. I do ask women to have their mammograms done at the same facility as this allows easier comparison with earlier mammograms and may reduce false positive readings. I find in my practice that most women are not aware of the differing recommendations. Virtually all of my patients choose to begin mammograms at age 40. I believe that is a reasonable choice and that women should, at the very least, have that option. I admit, I do have a bias. In my almost 40 years in healthcare, I have seen many women diagnosed with breast cancer in their 40s.

Karen Oh, MD: If they ask me personally, I usually tell them that there is a mortality benefit — meaning mammography does save lives — and the decision to screen or not screen in their 40s is kind of personal, so based on your family history or sometimes your breast density or your desire to start screening versus the risk of false positives. I generally encourage people, personally, to at least consider starting to screen in your 40s just because even though it’s not as frequent in that decade to have breast cancer as in the other decades, the difference it can make for you personally if you catch it early is a big difference. I usually counsel people to think about those issues and then direct them back to their provider to make that decision with them.

Angela DeRosa, DO: I will still recommend women start getting mammo’s at age 40 every other year and then yearly at age 50.The problem is any time in medicine when you go looking for things you often find things. Many women with early breast cancer screening (and increased frequency of mammo/other imaging) DCIS are getting treated very aggressively and active surveillance may be better. But there is a huge divide amongst specialist on this as well. The data and my gut tells me that starting later (45) and doing them less often makes sense, but if any women get breast cancer and I didn’t follow the more aggressive guidelines, I am in the line of fire for lawsuits and board sanctions. Also patient compliance is often a problem…..so I am asking every year, I may be lucky to get them to go every 2 years. That is the practicality.

Potential Patient Confusion

Oh: We actually polled some of our patients about that because you don’t need an order from a provider to get screening, so they’re making their own decisions and a lot of people do look on the Internet. But a lot of people still ask their providers, and if they still have questions, it tends to be when they come in and we see them for something then they ask us as well in Radiology in the Breast Center. So I think there are a lot of questions about when to start and I generally guide them back to “Do you want to screen and have the possibility that you will have a false positive” (couched in different terms, but that’s basically the issue) versus “You will know a little bit earlier, and there is a benefit to knowing earlier,” especially in the younger age group.

Brem: Women are confused. They are unclear what the recommendations actually are and simply cannot understand why three organizations recommend different screening schedules. We need to educate women and we need to partner with the media to reassure women. Mammography saves lives, more lives if screening begins at 40 and continues annually thereafter. However, there is a price which is callbacks and the possibility of benign biopsy. However, it should be the woman’s choice to decide whether the benefits outweigh the “harms” for her.

DeRosa: They are confused and not sure what to think. They look to me for guidance. Many women are terrified (because we have made them that way) about getting DCIS or cancer and want to be aggressive in screening. However, I am seeing a surge of women who believe that the radiation is more problematic.

Recommendations Always Changing

Boling: I believe changing guidelines are more of a problem for physicians, other providers of women’s healthcare, and the medical system in general. When you care for patients, and you are constantly changing your recommendations, I think it erodes trust in the physician-patient relationship. Also, if you follow the “begin at 45” guideline and a late stage breast cancer is diagnosed at a future date, it becomes harder to defend your decision when there are conflicting recommendations. Then there is the question of how insurers will respond to differing recommendations. And of course, it is confusing to patients when they read all these different recommendations.

DeRosa: There are divergent recommendations/clinical guidelines in many areas and this is no different. It has become a tyranny. Many insurance organizations are using these tonot pay for services. Also clinical guidelines are often different depending on the specialty focus. Also they tend to be 5-10 years behind emerging research. So those on the forefront may be punished or considered heretics for practicing outside of these guidelines….even if they are leaders and forging new exciting paths. Anyone can follow guidelines……medicine is an art form and the individual patient needs to be considered.

Wilkes: I strongly disagree with the recommendation against clinical breast examination in average risk women. There has been an increase in breast cancer in young women, younger than age 40. For those women, breast examination, whether it is self breast exam or an exam by a clinician is the only way for cancer to be detected. This is also true for women above age 40 with dense breasts. Recommending breast examination, with familiarity of it’s benefits and limitations should continue.