The U.S. Preventive Services Task Force recommendation comes as more women are being diagnosed with breast cancer at a younger age.
A national advisory panel has reduced the recommended age for breast cancer screening, suggesting women get their first mammogram at age 40 instead of 50 and continue every other year until age 74.
The U.S. Preventive Services Task Force recommendation comes as more women are being diagnosed with breast cancer at a younger age. It is a reversal of the panel’s previous recommendation suggesting women make an individual choice about getting a mammogram between ages 40 and 49. The recommendation applies to women at average risk of breast cancer, as well as those with a family history of breast cancer and those with dense breasts.
“More women in their 40s have been getting breast cancer, with rates increasing about 2 percent each year, so this recommendation will make a big difference for people across the country,” Task Force Chair Dr. Wanda Nicholson said in a press release. “By starting to screen all women at age 40, we can save nearly 20 percent more lives from breast cancer overall.”
The task force published the recommendations in 2023 as a draft open for public comment. The draft was finalized on Tuesday, April 30, and published in the Journal of the American Medical Association.
Mortality Rates Declining, but Breast Cancer Rates Increasing
According to the American Cancer Society, breast cancer is the second leading cause of cancer death for women in the United States, despite a steady decline in breast cancer mortality over the past 20 years. Most cases occur in women between the ages of 55 and 74, with the highest death rates occurring in women with a median age of 70.
Along with younger women, the new guidelines aim to help black women, who are 40 percent more likely to die of breast cancer than white women, according to Dr. Nicholson, who added that the new guidelines are just another step toward improving existing inequalities in the American health care system.
“We need to know how best to address the health disparities related to breast cancer so all women can live longer and healthier lives,” added Dr. John Wong, vice chair of the task force. “Clinicians must help reduce any barriers to patients getting the recommended screening, timely, equitable, and appropriate follow-up, and effective treatment of breast cancer.”
More Room for False Positives?
Adding another decade of testing increases the risk of experiencing at least one false positive during a mammogram, according to a 2022 University of California (UC)–Davis Health study published in JAMA Network Open. The study found that half of all women will experience at least one false positive over a decade of annual breast cancer screening. However, the risk of a false positive was considerably lower if screening occurred every other year (as recommended by the U.S. Preventive Services Task Force) as opposed to annually over a decade.
False positives are also more likely for women with denser breast tissue. The task force noted that more research is needed to show how screening with breast ultrasound or MRI might better help women with dense breasts.
“Findings from our study highlight the importance of patient-provider discussions around personalized health. It is important to consider a patient’s preferences and risk factors when deciding on screening interval and modality,” Michael Bissell, co-first author of the UC Davis Health study, said in a 2022 news release.
False positives are common. Although only 12 percent of 2D screening mammograms require more testing, less than 1 percent result in a cancer diagnosis, according to the UC Davis press release. Not only can they be expensive and timely, but they can also cause the patient to undergo unnecessary stress.
“Despite the important benefit of screening mammography in reducing breast cancer mortality, it can lead to extra imaging and biopsy procedures, financial and opportunity costs, and patient anxiety,” Diana Miglioretti, professor and division chief of biostatistics at UC Davis’ Department of Public Health Sciences, said in the 2022 press release.
Women with dense breast tissue will be given additional information at their cancer screenings under new rules adopted by the FDA.
Providers of mammograms will have to tell women that their tests are harder to interpret and suggest they speak with their doctors about more testing, the FDA says.
This will lead to greater detection of breast cancer earlier, advocates say.
Breast cancer is the second most common cancer in American women, after skin cancers, says the American Cancer Society. This year, about 300,000 new cases will be diagnosed, and about 43,700 women will die from breast cancer, the organization says.
“Today’s action represents the agency’s broader commitment to support innovation to prevent, detect and treat cancer,” Hilary Marston, the FDA’s chief medical officer, said.
Most states require that women be told when their mammogram finds they have dense breasts. The FDA decision applies a minimum standard for 8,700 facilities across the country, and states can still require more explicit wording, The Washington Post reported.
“Dense breasts have relatively less fatty tissue and higher amounts of glandular and fibrous connective tissue,” The Post wrote. “Nearly half of all women 40 and over have the condition. Dense breasts can appear white on a mammogram — but so does cancer, making it difficult for radiologists to detect tumors.” Women with dense breasts also face a higher risk of developing the disease.
Mammogram providers have 18 months to comply with the standards. Information about dense breasts will be included in a letter to patients and their physicians.
An epidemic of low-value screenings is driving millions of women to get unnecessary tests, treatments
Woman having a mammography scan. (Gorodenkoff/Shutterstock)
Getting older is a complicated business. As we age, trips to the doctor increasingly conclude with requisitions for different screenings—tests meant to help diagnose potential problems and keep us healthy for the long haul.
Although many tests used to detect cancer have been hailed as lifesaving miracles of modern medicine, some have a dark side. Concerns over the prolific use of mammograms for detecting breast cancer have been growing in the scientific community as journals publish research revealing that these tests come with their own risks. With roughly 70 percent of women in the United States older than 40 having mammograms at least every two years, it raises questions about their safety, whether information about potential dangers is being obscured, and who might really be benefitting from this widespread testing.
What if millions of women are fueling a billion-dollar industry with ever-increasing profits by using screenings that not only haven’t improved outcomes but may be harming the women it’s supposed to save?
Cancer in Our Society
Cancer is pervasive and widely feared because of its relentlessness and brutality and also because of the grueling nature of many cancer treatments. The National Cancer Institute spends billions of dollars on cancer research each year and cancer fundraisers are a perennial activity in our communities. Virtually every cancer has a month dedicated to its awareness. October is breast cancer awareness month, which it politely shares with liver cancer awareness in the United States.
As we get older, cancer is something we think about more, and our doctors push us to get tests and screenings to make sure cancer cells haven’t been seeded in our bodies.
Breast Cancer
Breast cancer deeply frightens many women (and yes, men can get it too). If you happen to be considered high-risk, screenings may start when you’re in your early 20s. In the United States, mammograms are considered to be the gold standard of testing for breast cancer, and there are now 2D and 3D varieties for women to choose from.
Mammograms use X-rays (a form of ionizing radiation) to take pictures of the breast. A machine is used in which a woman places her breast between two plates or paddles. It’s then compressed, and x-ray images are captured.
In a 2D mammogram, two images are taken, one from the top and one from the side, creating a 2D picture.
In 3D, or tomosynthesis, the process is largely the same, using slightly more radiation and capturing additional images, creating a three-dimensional picture of the breast.
Radiologists use the images to look for abnormalities, with breast cancer usually appearing as a white mass. If abnormalities are found, the patient is asked to come back for more tests, often an MRI, or to have a biopsy. Mammograms don’t diagnose breast cancer. The only way to diagnose breast cancer after an abnormality is seen is to do a biopsy.
Mammography: What You Should Know
Mammography does have risks, which all women should be aware of. The two main concerns of mammography are radiation exposure and overdiagnosis.
Because mammography uses a type of ionizing radiation, it comes with an inherent risk. We’re all exposed to radiation every day. Some of that radiation, such as the ultraviolet and infrared rays of the sun, is essential to our health (in appropriate doses). But we’re well adapted to these natural, low levels of radiation. The same isn’t true of man-made radiation.
The ionizing radiation used in mammograms is much stronger than that emitted by natural sources. At high levels, ionizing radiation can harm our tissues and organs and lead to cancer.
According to the American Cancer Society, the dose of radiation a person receives from a mammogram is about the same amount of radiation people get from their natural surroundings in a three-month period.
This is of concern because there are parts of the body that are particularly sensitive to radiation, and we should limit our exposure whenever possible. In fact, Cornell University’s Program on Breast Cancer and Environmental Risk Factors states that “the female breast is known to be highly susceptible to the cancer-causing effects of radiation when exposure occurs before menopause.” A mammogram is directing this radiation not only at the breast but also at the other organs inside the chest, such as the heart and lungs.
A cohort study published in the British Journal of Cancer in 2012 followed more than 500,000 women from 1973 until 2009. The study found that women who had received radiation treatment for breast cancer (high energy x-rays) had a significant increase in heart disease and lung cancer in the decades after their treatment.
The study clearly demonstrates a progressive increase in both risk and mortality from radiation-related heart disease and lung cancer with time (into the third decade) after exposure to radiation.
The study is one of many to raise questions about routine mammograms for women at low risk of breast cancer.
Overdiagnosis
The other issue with mammography is overdiagnosis. Overdiagnosis is a concern because mammograms can detect abnormalities that may not be cancer or that are cancers that would have regressed on their own but are treated once they’re discovered. That means that many women are exposed to chemotherapy, radiation therapy, and surgery that may not have been needed.
An article published in Public Health Research and Practice titled “What Is Overdiagnosis and Why Should We Take It Seriously?” offers a very good explanation of what overdiagnosis is and why it’s a problem, defining overdiagnosis this way:
“In cancer screening, overdiagnosed cancers are those that did not need to be found because they would not have produced symptoms or led to premature death.
“Overdiagnosis in cancer screening arises largely from the paradoxical problem that screening is most likely to find the slow-growing or dormant cancers that are least likely to harm us, and less likely to find the aggressive, fast-growing cancers that cause cancer mortality. This central paradox has become clearer over recent decades. The more overdiagnosis is produced by a screening program, the less likely the program is to serve its ultimate goal of reducing illness and premature death from cancer.”
An article published in The Lancet in 2013 argued that two 30- to 35-year-old randomized studies underestimated when they concluded that there was a 19 percent rate of overdiagnosis when screening with mammography.
The article’s author, Per-Henrik Zahl, a researcher with the Norwegian Institute of Public Health who has studied breast cancer overdiagnosis, argued that detection rates and the level of overdiagnosis have increased 100 percent or more as the sensitivity of mammograms has improved.
Zahl noted that when screening was introduced in Sweden and Norway, there was a 50 percent increase in invasive breast cancer. The total increase in diagnoses in Norway was 75 percent. He concluded that almost all of the increase in cancer detection through screening was due to lesions that normally go into spontaneous regression.
A comparative study published in the journal BMC Women’s Health in 2009 set out to quantify overdiagnosis in the Danish mammography screening program. Denmark is unique because only 20 percent of the population has been offered mammography over an extended period. Incidence rates of carcinoma in situ (stage 0 breast cancer) and invasive breast cancer were collected in areas with and without screening over 13 years, and 20 years before its introduction. The study found that in the screened women, the overdiagnosis rate was 33 percent.
A systematic review published in the British Medical Journal in 2009 tracked the incidence of breast cancer before and after the introduction of mammography screening in specific areas—the UK; Manitoba, Canada; New South Wales, Australia; Sweden; and parts of Norway—both seven years before and seven years after public breast cancer screening programs were implemented. The review found that overdiagnosis was estimated at 52 percent and concluded that one in three breast cancers detected in a population that was offered screenings were overdiagnosed.
As evidence of overdiagnosis has accumulated, it’s now recognized as the most serious downside of population-wide breast screening.
What Women Think
One of the main concerns with mammograms is that women may not be warned about the potential risks of and all the factors involved in breast cancer screenings. A cross-sectional survey of 479 women in the United States aged 18 to 97 published in the British Journal of Medicine set out to understand women’s attitudes to and knowledge of false-positive mammography results, as well as the detection of ductal carcinoma in situ (a type of stage 0 breast cancer) after screening mammography.
Ductal carcinoma in situ (DCIS) is defined as the presence of abnormal cells inside the milk duct in the breast. DCIS, which is considered an early form of breast cancer, is noninvasive, meaning that it’s still isolated, hasn’t spread out of the milk duct, and has a low risk of becoming invasive.
The survey concluded that women were aware of false positives, seeming to view them as an acceptable consequence of screening mammography. In contrast, most women were unaware that screening can detect cancers that may never progress (ductal carcinoma in situ) and felt that that information was relevant.
The study also found that only 8 percent of women thought mammography could harm a woman without breast cancer and 94 percent didn’t realize (doubted) that mammograms could detect cancers that might not progress. Few of the women in the study knew about DCIS, but 60 percent of the women wanted to take into account the possibility that any cancer detected may not progress.
Another study published in the Journal of the American Medical Association in 2013 looked at overdiagnosis and overtreatment of breast cancer and what physicians were telling patients about the risks of screening, specifically the possibility of overdiagnosis and overtreatment.
Less than 10 percent said they were told about the risks of mammograms by their physicians. Little more than half (51 percent) said they wouldn’t agree to a screening if it resulted in one overtreated person per one life saved. These numbers imply that millions of Americans might not choose to be screened if they knew the whole story, but unfortunately, 90 percent aren’t getting that information.
The Cancer Industry Recommendations
In the United States, mammograms are the standard screening used to detect breast cancer, and doctors usually begin speaking to their women patients about mammograms at about age 40.
Mammograms are approved by the Food and Drug Administration (FDA), which regulates the standards for mammography machines and the people who provide them. The FDA has also released several warnings about using thermography instead of mammograms, reminding the public that mammography is still the most effective primary breast cancer screening test.
Do Regular Mammograms Lead to Better Outcomes?
The question becomes, do regular mammograms lead to better outcomes? Well, it would depend on how you define better outcomes. If we’re talking about detecting breast cancer, it seems the answer is most certainly yes. Mammograms seem to be an excellent tool for detecting breast cancer. But if we define better outcomes as fewer women dying of breast cancer, then we seem to have entered a different territory.
An article, “Mammograms and Mortality: How Has the Evidence Evolved?” published in 2021 noted that a previous meta-analysis of mammogram studies revealed that mammograms have led to no significant reduction in all-cause mortality (death from any cause) for women of any age group. The article, by Amanda Kowalski, a health economist and the Gail Wilensky professor of applied economics and public policy at the University of Michigan Department of Economics, also noted that some trials even show imprecise increases in all-cause mortality across all age groups or within an age group. These findings were based on eight large randomized controlled trials that, combined, included more than 600,000 women.
A very large Canadian randomized screening trial published in the British Medical Journal followed nearly 90,000 women aged 40 to 59 over 25 years who were considered at average risk for breast cancer. One group of women received routine mammograms and the other didn’t. The somewhat surprising results were that mortality rates in both groups were almost identical. The overall conclusion of the study was that annual mammography in women aged 40 to 59 doesn’t reduce mortality from breast cancer any more than a physical examination. The study also noted that they found that the overdiagnosis rate among the mammography participants was 22 percent.
An analysis published in the Journal of the Royal Society of Medicine in 2015 concluded that mammograms have been promoted to the public with three promises that all seem to be wrong. The first is that they save lives, the second is that they save breasts, and the third is that they catch cancer early. The author, Peter C. Gotzsche, formerly with the Nordic Cochrane Center and co-founder of the influential Cochrane Collaboration, said mammogram screenings don’t help women live longer, that they increasemastectomies, and that many cancers are still caught at a very late stage.
It’s a sentiment other researchers have also expressed.
“The time has come to reassess whether universal mammographic screening should be recommended for any age group because the declines in breast cancer mortality can be ascribed mainly to improved treatments and breast cancer awareness; currently, we see that screening has only a minor effect on mortality (if any),” researchers from the Nordic Cochrane Centre wrote in the journal Radiology in 2011.
In 2013, the Swiss Medical Board—an independent health technology assessment initiative—was asked to prepare a review of mammography screening. After a panel reviewed the available evidence—and contemplated its implications in detail—they were extremely concerned. The Swiss Medical Board’s report was released on Feb. 2, 2014, and acknowledged that systematic mammography screening might prevent about one death from breast cancer for every one thousand women screened, even though there was no evidence that overall mortality was affected.
It also emphasized the harm caused by mammography, specifically false-positive test results and the risk of overdiagnosis. The report cites the following statistics from a study published in the Journal of the American Medical Association:
“For every breast-cancer death prevented in U.S. women over a 10-year course of annual screening beginning at 50 years of age, 490 to 670 women are likely to have a false positive mammogram with repeat examination; 70 to 100, an unnecessary biopsy; and 3 to 14, an overdiagnosed breast cancer that would never have become clinically apparent.”
Based on their findings, the board recommended that no new systematic mammography screening programs be introduced in Switzerland and that a time limit be placed on existing programs in the country, phasing them out entirely.
The Nordic Cochrane Centre, which is thought to be one of the world’s best and least-biased research institutions, conducted a systematic review to assess the effect of screening for breast cancer with mammography on mortality and morbidity. The trials they looked at included 600,000 women aged 39 to 74. The conclusions, published in 2013, are as follows:
“If we assume that screening reduces breast cancer mortality by 15 percent and that overdiagnosis and overtreatment is at 30 percent, it means that for every 2,000 women invited for screening throughout 10 years, one will avoid dying of breast cancer and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress including anxiety and uncertainty for years because of false positive findings.”
The study’s authors, Gotzsche andKarsten Juhl Jorgensen, said women should be fully informed of both the benefits and harms. They went so far as to write an evidence-based leaflet in several languages to help women understand the risks.
The Mammography Industry-Projected Earnings
What might perhaps be interesting to know is that mammography is a multibillion-dollar industry.
In September 2022, Vantage Market Research released a report that projected that earnings for the mammography market would be up to $3.2 billion by 2028 from $1.8 billion in 2021.
Growing markets in Asia are expected to provide most of that expansion. The report attributes the huge growth in the region to the existence of a significant number of mammography companies, the high adoption rate due to government measures that stimulate the industry, and increasing collaborations between the mammography industry and governments in the region.
Final Thoughts
Success when it comes to breast cancer really depends on the outcome we’re trying to achieve. If it’s early detection, then we seem to be doing a stellar job. But if our goal is lowering mortality rates, we seem to be in a gray zone and possibly moving backward. With the present technology—and its increasing sensitivity—we seem to have created many more cancer patients, perhaps unnecessarily, and are keeping women in the dark about the dangers.
Michael Baum, a professor emeritus of surgery and a visiting professor of medical humanities at University College London, is a British surgical oncologist specializing in breast cancer treatment and one of the architects of the UK’s national breast screening program.
Baum went from being one of the most determined supporters of breast cancer screening to one of its most vocal opponents.
In his book “The History and Mystery of Breast Cancer,” he explained why:
“The largest threat posed by American medicine is that more and more of us are being drawn into the system not because of an epidemic of disease, but because of an epidemic of diagnoses. The real problem with the epidemic of diagnoses is that it leads to an epidemic of treatments. Not all treatments have important benefits, but almost all can have harms.”
Digital mammogram can help screen for coronary artery disease in women
Breast arterial calcification (BAC) on digital mammography appeared to be a better predictor of coronary arterial calcification (CAC) in women than standard cardiovascular risk factors in a new study presented at the ACC meeting in Chicago, Illinois, US.
“The message is if a woman is getting a mammogram, look for BAC,” said principal author Dr. Harvey Hecht, director of cardiovascular imaging at Mount Sinai St. Luke’s Hospital in New York, US. “The more BAC a woman has, the more likely she is to have calcium in her heart’s arteries.” [ACC 2016, abstract 16-A-9366]
Hecht’s co-author Dr. Laurie Margolies, associate professor of medicine at Mount Sinai’s Icahn School of Medicine in Manhattan, US, said what was remarkable was the “very few false positives” for calcification. Mammography was 70 percent accurate at identifying women with atherosclerotic cardiovascular disease (CVD).
The study involved 292 women aged 60 or younger who had digital mammography and CT scans of the chest within a year. Seventy percent of the women with calcification in the breast arteries also had calcification in the coronary arteries – often a signal for coronary artery disease (CAD). The likelihood of calcification increased with age, high blood pressure and chronic kidney disease (CKD). Having BAC correctly identified women with atherosclerosis 63 percent of the time.
Currently, there is no consensus on using CAC as a screening test and primary care physicians only run extensive tests on patients when there is evidence of hypertension or a history of heart disease. “Our data show that mammogram is a more accurate detector of heart disease than other well-established cardiovascular indicators such as high cholesterol, high blood pressure and diabetes,” said Margolies.
BAC was noted in 124 or 42.5 percent of patients and was associated with increasing age (p<0.0001).The sensitivity and specificity of BAC >0 for CAC >0 were 63 and 76 percent, respectively, while positive and negative predictive values were 69 and 70 percent, respectively.
“There is a strong quantitative association between BAC and CAC… BAC appeared to be equivalent to both the Framingham Risk Score [FRS] and the 2013 Cholesterol Guidelines Pooled Cohort Equations [PCE] for identifying high-risk women,” said Margolies. “When women with established CAD were included, BAC>0 was significantly additive to both FRS [p=0.02] and PCE [p=0.04] for high-risk CAC.”
Multivariate analysis showed that early signs of plaque build-up in the coronary arteries were most strongly related to BAC. While CAC was twice as likely with advancing age or high blood pressure, it was thrice more likely with BAC.
“Using this information would allow at-risk women to be referred for standard CAC scoring and for clinicians to start focusing on prevention,” said Hecht. Women, particularly those aged 40-75 years who are the target of mammogram screening every 2 years, could be ideal candidates for atherosclerotic CVD risk assessment.
In an accompanying editorial, Drs. Khurram Nassir and John McEvoy from the Center for Healthcare Advancement and Outcomes at Baptist Health South Florida in Florida, US said the findings support BAC documentation in mammography reports. “Whether the best use of BAC is to trigger additional testing or to directly inform preventive treatment decisions by flagging high-risk women or reclassifying traditional heart disease risk estimate is worthy of further discussion.”
A coming conference aims to reconcile different groups’ conflicting advice on the breast-cancer screening test
WSJ’s Sumathi Reddy joins Lunch Break With Tanya Rivero and discusses efforts to streamline the numerous recommendations for when women should get mammograms and breast-cancer screenings.
An influential federal panel issued its final recommendations Monday for when women should start getting mammograms, underscoring the conflicting advice on the issue coming from major cancer and women’s health groups.
One of those groups, the American College of Obstetricians and Gynecologists, or ACOG, has invited more than 30 organizations to participate in a conference later in January to try to reach a consensus opinion. It said many women have been confused by the groups’ disagreements, including on what is the best age to begin mammograms and how frequently to get them.
The final recommendations from the U.S. Preventive Services Task Force say mammograms should be done every two years for women ages 50 to 74. Women in their 40s at average risk for breast cancer should consider the test depending on their comfort level. The recommendations, published in the journal Annals of Internal Medicine, are mostly similar to the task force’s previous guidelines, from 2009, but allow more leeway for women in their 40s to consider the test.
The American Cancer Society in October revised its own guidelines, pushing back the recommended start time for mammograms to age 45 from 40. It recommends the test every year until age 55, and then every two years.
Other influential groups, including ACOG and the National Comprehensive Cancer Network, a nonprofit alliance of leading cancer centers, recommend mammograms begin at age 40 and be done every year.
Medical groups decide on guidelines by weighing the potential benefits of breast-cancer screening, mainly lives saved through early cancer detection, against possible harms, including false positives that can lead to unnecessary tests and treatment. Weighing the various factors differently can change the conclusions. The guidelines are designed for women of average risk.
ENLARGE
Nancy Keating, a primary-care provider at Brigham and Women’s Hospital in Boston, says in the past couple of years a “substantial” number of her female patients in their 40s have delayed getting regular mammograms to a later age. “Many women are confused [by the various recommendations] and it is challenging,” she says. Dr. Keating says she works with patients to assess their cancer risk and give them a sense of whether they are average or above-average risk.
Generally, recommendations from the Preventive Services Task Force must be offered as part of private insurance plans under the 2010 Affordable Care Act. To allay concerns about mammogram coverage, however, Congress added an exception to the law that requires insurers to cover annual mammograms starting at age 40.
Jill Rabin, an OB-GYN with Northwell Health System in Long Island, N.Y., says she follows the ACOG recommendations in advising most of her patients to start annual mammograms at age 40. She says getting screened every other year can lead people to miss a test “and that can be very, very dangerous because a lot can happen in that time.”
“I know that I’ve saved lives” by diagnosing patients with breast cancer who were younger than 45 and with no risk factors, Dr. Rabin says. “We can’t let these people down by postponing their chance at early detection.”
Dr. Jill Rabin, an OB-GYN in New York, says she follows the ACOG recommendations in advising most of her patients to start annual mammograms at age 40.
Experts have long stressed that early detection of cancer can save lives. Studies have estimated that annual screenings can cut the risk of death by 15% to 40%. Medical groups’ mammogram guidelines historically were largely in sync, but recent research has caused them to diverge.
“We have tried to really clarify what the science is telling us about the benefits of mammography screening for women age 40 to 74,” says Kirsten Bibbins-Domingo, vice-chairwoman of the Preventive Services Task Force and a professor of medicine at University of California, San Francisco. While regular mammograms for women in their 40s are effective in reducing deaths from breast cancer, the benefit is less than it is for older women and the potential harms are greater, the task force noted.
Dr. Bibbins-Domingo says the task force’s latest recommendations aim to clarify its 2009 guidelines, which “were widely misinterpreted as a recommendation against screening for women in their 40s.”
An American Cancer Society study published in December in the American Journal of Preventive Medicine found that four years after the task force first stopped recommending mammograms for women in their 40s the prevalence of the tests didn’t significantly change for women in that age group. The study, which compared federal data from 2008 to 2013, the latest available, did find that there was a significant decrease in physicians recommending mammograms to women in their 40s.
Therese Bevers chairwoman of the breast cancer screening and diagnosis guidelines panel for the National Comprehensive Cancer Network, says she plans to attend the ACOG conference on mammogram guidelines, but believes it may be difficult to reach a consensus among the various groups.
Dr. Kirsten Bibbins-Domingo, vice-chairwoman of the Preventive Services Task Force, says the panel’s new recommendations reflect ‘what the science is telling us about the benefits of mammography screening.’
The conference, in Washington, D.C., is planned for Jan. 28 and 29. “We look forward to a positive outcome of this conference that helps to avoid the confusion that currently exists among the women we treat,” ACOG said Monday.
Dr. Bevers says she recommends women start annual mammograms at age 40. “We just feel that the task force placement on the harms is a bit excessive,” she says. Harms such as a false positive requiring a repeat ultrasound or a needle biopsy are outweighed by the potential for lives saved, she believes.
In a separate study also published in the Annals of Internal Medicine Monday, researchers found that false-positive results are highest among women 40 to 49 years old, leading to additional imaging. The study analyzed data from more than 400,000 women ages 40 to 89.
But Dr. Bevers says that based on clinical experience and research, after the additional tests performed following a false positive there is very rarely a wrong diagnosis.
Stephanie Nichols, a patient of Dr. Keating’s at Brigham and Women’s Hospital, decided around age 40 to wait until she turns 45 to have her first mammogram after learning she was at low risk for developing breast cancer. Ms. Nichols, now 44, says she was also influenced by talking about false positives and the additional testing and stress those can lead to. “I didn’t want to go through that,” she says. “I decided I would just keep doing breast self-exams and see her [doctor] regularly.”
The task force guidelines don’t specifically recommend regular mammograms for women 75 years and older and call for more research in this area. “There is not enough evidence for us to say with certainty what the benefit is,” Dr. Bibbins-Domingo says.
Susan K. Boolbol, chief of the division of breast surgery at Mount Sinai Beth Israel in New York City, disagrees with that conclusion by the task force. She says she presented research recently at the San Antonio Breast Cancer Symposium showing thatmammograms in women age 75 and older are justified.
Dr. Boolbol reviewed the mammography results of 2,057 women age 75 and older over two years at Mount Sinai. The breast cancer detection rate was 4.9 per 1,000 screenings, nearly double the rate the American College of Radiology uses as a standard for when mammograms should be used, she says.
“We should not base recommendations on an age limit,” Dr. Boolbol says. “It should really be based on the woman’s expected lifespan and her health status.”
Conventional mammography is a screening procedure constrained by low specificity in the detection of breast cancer. Approximately 40% of women undergoing mammography screening have dense breast tissue, and conventional mammographic imaging has a sensitivity range of only 50%-85% for malignant lesions. Magnetic resonance imaging (MRI) is now recommended for breast cancer screening in high-risk patients. However, approximately 15% of patients cannot tolerate MRI. These are the clinical situations in which positron emission mammography (PEM) and breast-specific gamma (BSG) camera systems fulfill a need for primary breast cancer imaging. Because breast cancer is the most common malignancy and the second most common cause of cancer death among women, many nuclear medicine imaging techniques are essential in the evaluation and therapy of patients with this disease. Nuclear medicine surgical techniques consist of sentinel lymph node localization and the use of radiolabeled seeds for intraoperative localization of nonpalpable breast cancers. The Food and Drug Administration (FDA) has approved the PEM Flex Solo II scanner, which has the capability for stereotactic biopsy, with an array of pixelated lutetium yttrium orthosilicate (LYSO) crystals, position-sensitive photomultiplier tubes (PS-PMT), and a spatial resolution of 2.4 mm. Clear PEM is a scanner in development with cerium-doped LYSO (LYSO:Ce) crystals, multipixel avalanche photodiodes, depth of interaction measurement with a resolution of 1.3 mm. The Dilon 6800 Gamma Camera is a BSG device approved by the FDA with stereotactic biopsy guidance capability, a pixelated array of sodium iodide crystals, PS-PMTs, and an extrinsic spatial resolution of 6 mm at 3 cm from the camera. GE has just received clearance from the FDA for a molecular breast imaging camera, the Discovery NM 750b, with pixelated cadmium zinc telluride crystals, semiconductor photoelements and an extrinsic resolution of 3.5 mm at 3 cm. The Society of Nuclear Medicine has issued guidelines for BSG camera image interpretation recommendations and clinical indications. Different crystals and camera architectures are under investigation to further improve resolution for both PEM and BSG imaging.
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