Archive for the ‘Women’s Health’ Category

New Mammography Guidelines

Wednesday, December 16, 2015 // Women's Health

Here is a summary from the publication Journal Watch:

American Cancer Society Updates Mammography Guidelines for Average-Risk Women
American Cancer Society Updates Mammography Guidelines for Average-Risk WomenRecommendations move closer to those of the USPSTF — but differences remain.
Recommendations move closer to those of the USPSTF — but differences remain.
Andrew M. Kaunitz, MD

Based on input from clinicians, public health specialists, laypeople, and a commissioned review, the American Cancer Society (ACS) has issued its first guideline update since 2003 regarding screening mammography for average-risk women (no personal history of breast cancer, known mutation associated with excess risk, or history of chest wall radiation at a young age). Recommendations are delineated as strong (consensus that the benefits of adhering to the recommendation outweigh undesirable effects) or qualified (clear evidence of benefits but less certainty about benefit–harm balance or women’s preferences that could influence their decisions). The new guidelines are as follows:Age

  • Age 40–44: Optional annual screening mammography (qualified)
  • Age 45: Begin screening (strong)
  • Age 45–54: Annual screening (qualified)
  • Age ≥55: Biennial screening with option to continue annual screens (qualified)
  • Continue screening as long as overall health is good and life expectancy is ≥10 years (qualified).
  • Any age: Clinical breast examination (CBE) for screening is not recommended (qualified).

Comment: The updated ACS recommendations reduce the potential for harms (overdiagnosis and unnecessary additional imaging and biopsies) and move closer to the guidelines of the U.S. Preventive Services Task Force (USPSTF; i.e., begin biennial screening at age 50; NEJM JW Womens Heath Dec 2009 and Ann Intern Med 2009; 151:716).As one editorialist points out, the ACS recommendation to begin screening at age 45 is based on observational comparisons between screened and unscreened cohorts, a type of analysis the USPSTF does not consider because of concerns about bias. The ACS’s recommendation for annual screening in women aged 45–54 is based in part on the findings of a recent study showing that, for premenopausal (but not postmenopausal) women, tumor stage was higher and size larger for screen-detected lesions among women undergoing biennial screens. The ACS recommendation against screening CBE, stemming from the absence of data supporting CBE’s benefits (alone or with screening mammography), represents a dramatic change from the society’s prior stance. Moreover, in leaving their 2003 guidance regarding breast self-examination unchanged, the ACS continues to recommend against this latter practice. Overall, these updated guidelines should result in more women starting screening mammograms later in life as well as opting for biennial screening, meaning fewer lifetime screens. Also, fewer breast examinations during well-woman visits will allow clinicians more time to assess family history and other risk factors for breast cancer, as well as to maintain dialog about screening recommendations. In my practice, I will continue to encourage screening per USPSTF guidance (begin biennial screens at age 50) for my average-risk patients, while recognizing that many will be more comfortable starting screening at an earlier age and annually thereafter. – See more at: http://www.jwatch.org/na39390/2015/10/22/american-cancer-society-updates-mammography-guidelines#sthash.I7aWUyaH.dpuf

My two cents from Dr. Jennifer Wallace:

Previously the standard of practice was for women to have annual mammograms starting at age 40. We now have two agencies who have recommended reduced frequency of screening mammograms for average risk women. The difficulty with screening procedures, as always, is to find the right balance between screening frequently enough to detect problems at an easily curable stage vs. screening too often, leading to further possibly unnecessary testing and anxiety.

Previously the standard of practice was for women to have annual mammograms starting at age 40. We now have two agencies who have recommended reduced frequency of screening mammograms for average risk women. The difficulty with screening procedures, as always, is to find the right balance between screening frequently enough to detect problems at an easily curable stage vs. screening too often, leading to further possibly unnecessary testing and anxiety.

The new recommendations by the American Cancer Society for less frequent mammograms are somewhat “soft”, leaving us a lot of wiggle room. Their recommendations, other than to start screening at age 45, are “qualified”, meaning that the benefits are known, but there is less certainty about whether the harms of screening on the proposed schedule outweigh the benefits. Further, since we have recently started using “3D mammograms”, which are less likely to miss small or early cancers, I wonder if the “benefit vs. harm” calculation could possibly change in favor of annual screening again.

Unfortunately, it may take years before the harms, if any, of the reduced screening are known. I will look forward to finding out those results. Meanwhile, for now I am leaning toward continuing annual mammograms, particularly in women who are taking postmenopausal hormone replacement. As always, I will be open to discussion with my patients about their preferences, and stay open to change as more information becomes available.

Jennifer Wallace MD

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