ACP: Mammogram screening in your 40s should be individualized

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The American College of Physicians (ACP) has issued a new set of guidelines for women in their 40s, recommending that mammography screening decisions be made case-by-case. Clinicians are advised to discuss the benefits and harms of screening with patients, including individual cancer risk and screening preference. The full recommendations were published in the April 3 issue of the Annals of Internal Medicine.

"There are important benefits to screening mammography, but we believe the decision to be screened should be based on an informed conversation between a patient and her physician," said Douglas K. Owens, MD, MS, a researcher with the Veterans Affairs Palo Alto Health Care System and a professor of medicine at the Stanford University School of Medicine, who chaired the committee that developed the guidelines. "In our view, the evidence doesn't support a blanket recommendation for women in this age group."

There has been much debate about screening mammography for women in their 40s, however there has been little debate about the merits of such screenings for 50- to 70-year-old women. Evidence for screening of younger women isn’t as clear cut, the organization said.

ACPs recommends that clinicians:

  • Periodically perform individualized assessment of risk for breast cancer to help guide decisions about screening mammography;
  • Inform women ages 40 to 49 of the potential benefits and harms of screening mammography; and
  • Base screening mammography decisions on benefits and harms of screening as well as a woman's preferences and breast cancer risk profile.

The organization emphasized the importance of using a woman's concerns about breast cancer and screening to help guide decision-making about mammography. The group expects the potential reduction in breast cancer mortality associated with screening to outweigh other considerations for many women.

"We still think many women will choose to get mammography, and we're supportive of that," said Owens. "The most important thing is that women be well-informed about the decision they're making."

In response to the ACP guidelines, the American Cancer Society issued a statement emphasizing that it continues to recommend that women begin getting yearly mammograms when they turn 40.

ACS’s Director of cancer screening, Robert Smith, PhD, said there is plenty of evidence that mammograms are beneficial and can save the lives of younger women as well.

"The American Cancer Society and other organizations have endorsed mammography screening for women in their 40s because direct and inferential evidence supports its value in reducing morbidity [injuries] and mortality [deaths] from breast cancer, the second leading cause of cancer death in women," he said.

There are other groups that recommend mammograms every 1 or 2 years for women in their 40s, such as the US Preventive Services Task Force and the American College of Obstetricians and Gynecologists, ACS said.

While the ACP guidelines state that mammograms can bring down breast cancer deaths by approximately 15 percent among women in their 40s, Smith believes newer studies show the benefit to be much greater around 40 percent or more.

And though the ACP guideline emphasized that a woman should discuss individual risk of breast cancer to determine a screening routine, ACS stated that predicting breast cancer risk for any one woman can very difficult.

"While such factors as family history of breast cancer, breast density, and genetic mutations may help identify women at increased risk, most women with diagnosed breast cancer have none of these risk factors," wrote the University of Washington's Joann Elmore, MD, MPH, and John Choe, MD, MPH, in an editorial provided with the Annals of Internal Medicine report.

Smith said that point is very important. "If we were to screen only those women in their forties who had significant, known risk factors, we would fail to detect the majority of breast cancers that arise during that decade of life," he said.

Physicians in the trenches have also voiced puzzlement over the ACP guidance. One breast specialist, Rebecca G. Stough, MD, clinical director of Breast MRI of Oklahoma, LLC, and radiologic director of Mercy Women’s Center in Oklahoma City, said that the benefits of screening beginning at age 40, unless clinically indicated prior to that because of risk factors, is well documented. “I cannot understand why the American College of Physicians would make such a statement.