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Altered Approach to Mammographic Screening for Breast Cancer

New USPSTF guidelines for mammographic screening indicate the need for more individualization in screening decisions.

Although mammographic screening clearly has lowered breast cancer mortality, the most efficacious approach to screening is unclear. After systematically reviewing results of randomized trials and statistical models of screening effects, the U.S. Preventive Services Task Force (USPSTF) updated its 2002 guideline (JW Gen Med Mar 19 2002) that recommended screening mammography every 1 to 2 years for all women older than 40. Importantly, the 2009 recommendations (JW Womens Health Nov 16 2009) do not apply to women who are at excess risk for breast cancer because of known genetic mutations or histories of chest radiation, because insufficient evidence is available to make recommendations for this group.

The first change in the 2009 USPSTF guidelines is to recommend against universal screening mammography for younger women (age range, 40–49) but to urge individualized informed decision making, based on specific benefits and harms for women in this age group. This change was based on information about the high rates of false-positives and resulting invasive procedures in younger women.

The second change is to recommend biennial screening mammography for older women (age range, 50–69). Models indicate that biennial screening for this group maintained about 80% of the benefit of annual screening while halving the number of false-positive results. The recommendations also extend screening to women in the 70- to 74-year-old group but note that the benefits in this age group are much lower because of deaths caused by other diseases. Current evidence is insufficient to assess the benefits and harms of screening mammography in elders (age, 75).

The USPSTF also found insufficient evidence to assess the benefits and risks of clinical breast examination, digital mammography, and magnetic resonance imaging versus film mammography. The task force concludes that moderate certainty exists that harms of breast self-examination outweigh benefits and recommends against teaching the technique.

These nuanced recommendations about breast cancer screening have been sensationalized in the media and misinterpreted by many physicians. Although the new guidelines represent rational approaches to resource use (similar to those adopted in other countries), they also require more thought, patient counseling, and individualization than U.S. physicians have provided heretofore. Better tools for risk assessment would help patients and their healthcare providers to make informed decisions about the most effective approaches to breast cancer screening.

— Robert W. Rebar, MD

Published in Journal Watch General Medicine December 31, 2009

Reader Remarks:

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• Mammography vs. Thermography
  Shirley R. Holmes, Retired hospice administrator, 2 Jan 2010 8:55 AM EST
  The medical community needs to research the cumulative affects of mammography over time, satisfy themselves that thermography is much safer... [more]