Panel: Screening Mammograms Should Start at 50

U.S. Preventive Services Task Force Recommends Routine Mammography Screening Every 2 Years

By Salynn Boyles
WebMD Health News

Reviewed By Louise Chang, MD

Nov. 16, 2009 –- A government appointed expert panel is calling for huge changes in breast cancer screening in the United States, but a leading cancer group is highly critical of the move.

In newly revised guidelines, the U.S. Preventive Services Task Force (USPSTF) now recommends against routine mammography screening for average-risk women in their 40s.

USPSTF also says women between the ages of 50 and 74 should have mammogram screenings every two years instead of every year.

Routine screening is not recommended for women older than 74.

In addition, the government task force:

• Concluded women and their doctors should base the decision to start mammography before age 50 on the woman's individual risks and preferences.
• Recommends against breast self-exams based on findings from two large studies showing the practice to have no value.
• Concluded more evidence is needed to determine if clinical breast exams performed by trained medical professionals are useful.
• Concluded more research is needed before recommendations for or against mammography screening after age 74 can be made.
• Concluded there is not enough evidence to know if the newer digital mammography or MRI are superior to traditional film mammography.

ACS Does Not Support Changes

The dramatically revised guidelines were based on a comprehensive analysis of the research exploring the benefits and risks of breast cancer screening and a risk-benefit model commissioned by USPSTF.

Task force vice-chairwoman Diana B. Petitti, MD, MPH, says the new recommendations do not mean average-risk women younger than 50 and older than 74 should never be screened.

Rather, they are meant to foster discussion between these women and their doctors about the risks vs. benefits of routine screening.

Potential risks include anxiety, unnecessary biopsy, and unnecessary treatment of cancers that would never become life threatening.

"A woman who still wants to be screened after having the conversation with her clinician and considering the balance of benefits and harms should absolutely be screened," Pettiti tells WebMD.

The American Cancer Society will continue to recommend annual routine mammography screening for all healthy women age 40 and over, ACS Chief Medical Officer Otis Brawley, MD, confirmed in a statement issued today.

"This is one screening test I recommend unequivocally, and would recommend to any woman 40 and over, be she a patient, a stranger, or a family member," he notes.

Mammography Screening Every 2 Years

All agree that annual mammography screenings save lives.

But based on the research analysis and risk-assessment model, the task force concluded the harms of telling women to have a mammogram every year starting at age 40 outweigh the benefits.

According to the newly published research analysis:

• 1,904 women between the ages of 39 and 49 would need to be invited for screening to have one breast cancer death prevented.
• 1,339 women between the ages of 50 and 59 would need to be invited for screening to prevent one death.
• 377 women between the ages of 60 and 69 would need to be invited for screening to prevent one death.

According to the risk-assessment model, about 60% more false-positive results could be expected for every 1,000 mammograms performed when screening is started at age 40 instead of 50.

Jeanne S. Mandelblatt, MD, MPH, of Georgetown Lombardi Comprehensive Cancer Center led the research team that developed the model.

The team concluded that mammogram screening every two years achieves most of the benefits of annual screening with far fewer false-positives and other negative outcomes.

"Mammogram screening clearly has benefits, but there are potential risks as well," she tells WebMD. "Women need to discuss their own individual balance of risks and benefits with their health care providers."

Brawley: 'Women Want Mammograms'

The American Cancer Society's Brawley says surveys show women understand the limitations of mammography but still place a high value on breast cancer screening.

"With its new recommendations, the USPSTF is essentially telling women that mammography at age 40 to 49 saves lives; just not enough of them," he notes.

In 2003, an ACS expert panel reviewed much of the same research as the USPSTF panel but came to very different conclusions about who should be screened and how often, ACS volunteer president Elizabeth T.H. Fontham, MD, tells WebMD.

She worries the competing recommendations will confuse women and keep those who most need mammograms from getting them.

"It would be a terrible thing if women conclude that mammography screening is not useful," she says. "One thing we know for sure is that mammography saves lives. That is true for women in their 40s, for women 75 and older, and for all women in between."

Fox Chase Cancer Center Director of Mammography Kathryn Evers, MD, tells WebMD she will continue to recommend annual screening to her patients in their 40s and to healthy patients who are 75 and older.

She is concerned that health insurance providers may deny coverage for routine mammogram screening to average-risk women younger than 50 and older than 74, based on the new USPTF recommendations.

"Mammography is not a perfect tool, but it saves lives," she says. "Right now it is the best tool we have to prevent deaths from breast cancer, and women want their insurance to pay for it."

In a joint statement emailed to WebMD, the American College of Radiology (ACR) and the Society of Breast Imaging say the new guidelines could cost women's lives.

Calling the guidelines a "cost-cutting" measure, the ACR states that "two decades of decline in breast cancer mortality could be reversed and countless American women may die needlessly from breast cancer each year."

In the statement, Carol H. Lee, MD, chairwoman of the ACR's Breast Imaging Commission, calls the USPSTF recommendations "unfounded." Lee adds, "Mammography is not a perfect test, but it has unquestionably been shown to save lives -- including in women aged 40-49."

SOURCES: U.S. Preventive Services Task Force, Annals of Internal Medicine, Nov. 17, 2009; vol 151: pp 716-727.

Nelson, H.D. Annals of Internal Medicine, Nov. 17, 2009.

Diana Petitti, MD, vice chairwoman, U.S. Preventive Services Task Force; professor of biomedical informatics, Fulton School of Engineering, Arizona State University.

Elizabeth T.H. Fontham, MD, American Cancer Society national volunteer president; dean, School of Public Health, Louisiana State University.

Jeanne S. Mandelblatt, MD, MPH, Georgetown Lombardi Comprehensive Cancer Center.

Kathryn Evers, MD, director of mammography, Fox Chase Cancer Center, Philadelphia.

Karla Kerlikowske, MD, San Francisco Veterans Affairs Medical Center, San Francisco.

Joint Statement, American College of Radiology and the Society of Breast Imaging.

New release, Georgetown University Medical Center.

New release, American College of Physicians.

New release, American Cancer Society.

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