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Most women gear up for their first annual mammogram at age 40 to screen for breast cancer – but some experts are questioning whether this is too soon and too frequent.
The American College of Physicians (ACP) recently released new guidance for breast cancer screening based on risk, which was published in the Annals of Internal Medicine.
The updated guidance suggests that all average-risk, asymptomatic females between 50 and 74 years old should undergo mammograms every two years.
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Those who are between 40 and 49 years of age are encouraged to discuss their risk of breast cancer with a doctor, weighing the potential benefits and harms of screening.
The ACP cautioned that unnecessary screening can produce false positive results, psychological distress, over-diagnosis, over-treatment, additional testing and radiation exposure.
Women 75 and older who are asymptomatic and average-risk, as well as those with limited life expectancy, can discuss with their doctors about halting screening, the ACP added.
“This is because the benefits of screening beyond age 74 are reduced or uncertain, while potential harms, such as over-diagnosis, become more likely with increasing age,” they stated.
For patients who have dense breasts, the ACP encourages doctors to consider supplemental digital breast tomosynthesis (DBT), often called 3D mammography.
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“Decisions should consider potential benefits and harms, radiation exposure, availability, patient values and preferences, and cost,” the group wrote. “However, ACP advises against using supplemental MRI or ultrasound for screening in this population.”
This guidance was backed by ACP’s Clinical Guidelines Committee, which defined “average-risk” as women who do not have a personal breast cancer history or diagnosis of a high-risk breast lesion, BRCA 1 or 2 genetic mutation, another familial breast cancer risk syndrome, or history of high-dose radiation therapy to the chest at a young age.
Jason M. Goldman, MD, president of ACP, commented in a statement that screening for breast cancer is “essential and should be guided by the best available evidence.”
“ACP developed this guidance to provide physicians and females with the information they need to make breast cancer screening decisions, including when to start and discontinue, how often to screen and which methods to use for screening,” he said.
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In an interview with Fox News Digital, Lauren Carcas, MD, medical oncologist with Miami Cancer Institute, part of Baptist Health South Florida, scrutinized these new guidelines, saying they “add to the confusion of screening recommendations.”
“Generally, this recommendation is based on a risk-based screening approach to determine who needs more frequent and/or aggressive screening versus who could safely space out screening frequency,” she said.
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“Doing so implies that all women have equal access to individualized discussions and nuanced risk-assessment through either their primary care or gynecologic physicians.”
These biennial screening recommendations could “potentially widen disparities and increase the likelihood of missing cancer in the populations that are already impacted by barriers to care,” according to Carcas.
The new recommendation differs from the other institutes like the American Society of Breast Surgeons and the American College of Radiology/Society of Breast Imaging, which call for annual mammography screenings, typically starting at age 40.
The screening interval “remains the most consequential disagreement between all of the medical societies and the screening task force,” Carcas noted.
“All major U.S. societies agree that mammography screening should be available starting at age 40,” she said. “However, by age 25, all women should undergo a formal breast cancer risk assessment in order to direct their ongoing screening.”
Carcas also challenged ACP’s recommendation against supplemental MRI and ultrasounds for women with dense breast tissue, in favor of only using DBT.
“The radiologic societies very strongly recommend the addition and consideration of breast ultrasound and/or MRI for more complete and accurate imaging,” she said.
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Women who have a 20% or higher lifetime risk of developing breast cancer are considered high-risk, according to Carcas, and should undergo annual screening with supplemental ultrasound and MRI consideration.
“For the average-risk woman, the conversation will be more nuanced between the patient and her physician,” she said. “Depending on the individual’s preference and the recommendation of her gynecologist or primary care, the patient would screen with mammogram on an annual basis or biennially, per shared-decision making.”
Carcas pointed to a “gap in evidence” regarding mortality risk between annual and biennial screening, as there has not been a randomized controlled trial investigating the difference between the two.
“Most women who are diagnosed with breast cancer would certainly be grateful to have it diagnosed at an earlier stage, when there is less likely need for chemotherapy and other aggressive modalities of treatment,” she said.
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The doctor said she still plans to recommend annual screenings to her patients and to offer ultrasounds and MRIs to those who require it.
“I remain hopeful that this new recommendation from ACP will not alter insurance coverage for patients undergoing screening, particularly in light of the differing recommendations among medical societies,” Carcas added.
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