Less than two months after the U.S. Preventive Services Task Force (USPSTF) set off a national controversy with its revised recommendations for mammography screening, the American College of Radiology (ACR) and the Society of Breast Imaging (SBI) have issued recommendations calling for breast cancer screening to begin at age 40 and even earlier for high-risk patients.
The recommendations are published in the January issue of the Journal of the American College of Radiology in an article authored by Carol H. Lee, MD, from the department of radiology at Memorial Sloan-Kettering Cancer Center in New York City, and 14 colleagues.
The USPSTF recommended against routine screening for women aged 40 to 49, and biennial screening for women aged 50 to 74. These recommendations were “met with widespread concern among the breast imaging community and the public,” according to the authors. “The ACR and SBI along with the ACS [American Cancer Society] and other organizations strongly criticized the USPSTF recommendations, disagreeing with the conclusions reached by their analysis of the existing data and with the method by which their recommendations were formulated. Amidst all the furor, the ACR and SBI firmly stand behind their recommendation that screening mammography should be performed annually beginning at age 40 for women at average risk for breast cancer.”
“The significant decrease in breast cancer mortality, which amounts to nearly 30 percent since 1990, is a major medical success and is due largely to earlier detection of breast cancer through mammography screening,” said Lee, in a statement released by the ACR. “Evidence to support the recommendation for regular periodic screening mammography comes from the results of several randomized trials conducted in Europe and North America that included a total of 500,000 women. Overall, based on a meta-analysis of the RCTs, there was a 26 percent reduction in mortality."
In addition to the recommendation calling for annual screening for women (at average risk for breast cancer) beginning at age 40, the ACR and SBI recommend that women younger than 40 years of age should start screening in certain cases:
- BRCA1 or BRCA2 mutation carriers: by age 30, but not before age 25;
- Women with mothers or sisters with pre-menopausal breast cancer: by age 30 but not before age 25, or 10 years earlier than the age of diagnosis of relative, whichever is later;
- Women with a greater than 20 percent lifetime risk for breast cancer on the basis of family history (both maternal and paternal): yearly, starting by age 30 but not before age 25, or 10 years earlier than the age of diagnosis of the youngest affected relative, whichever is later;
- Women with histories of mantle radiation received between the ages of 10 and 30: beginning eight years after the radiation therapy but not before age 25; and
- Women with biopsy-proven lobular neoplasia, ADH, DCIS, invasive breast cancer, or ovarian cancer regardless of age.
The ACR and SBI also issued guidelines and recommendations for the use of ultrasound and MRI in breast cancer screening. Ultrasound, in addition to mammography, can be considered for high-risk women for whom MRI screening may be appropriate but who cannot have MRI for any reason, as well as for women with dense breast tissue.
MRI can be used for women who:
- Are proven carriers of a deleterious BRCA mutation (annually starting by age 30);
- Are untested first-degree relatives of proven BRCA mutation carriers (annually starting by age 30);
- Have a greater than 20 percent lifetime risk for breast cancer on the basis of family history (annually starting by age 30);
- Have histories of chest irradiation (annually starting 8 years after the radiation therapy);
- Have newly diagnosed breast cancer and normal contralateral breast by conventional imaging and physical exam (single screening MRI of the contralateral breast at the time of diagnosis); and
- Have between 15 and 20 percent lifetime risk for breast cancer on the basis of personal history of breast or ovarian cancer or biopsy-proven lobular neoplasia or ADH.