New breastcancer guidelines are no longer as aggressive as before.
ACS’ step away from aggressive approach to mammograms prompts more debate
New guidelines for mammograms released Tuesday by the American Cancer Society represent a significant step back from the aggressive early and universal screenings the country began 18 years ago.
The changes — which include raising the age that a woman of average risk begins regular screening from 40 to 45 — are a recognition of the growing concern that the benefits of mammograms may have been oversold, as well as the anxiety and needless treatments caused by overdiagnosis and false positives from the tests.
Richard Wender, a member of the breast cancer guideline panel and a former president of the ACS, said that the new recommendations confirm that mammography is the most important thing a woman can do to reduce her chance of dying of breast cancer but that they provide a more “personalized and tailored approach.”
“Over the past couple of years, there has been so much confusion that some women and some clinicians have really lost confidence in mammography. We hope this extraordinary and thorough review will calm that worry,” Wender said.
The more conservative approach outlined by the ACS calls for women to start yearly screening at age 45 and then transition to screening every two years at age 55 — which the panel used as a surrogate for menopause. It also recommends that doctors stop screening women with a life expectancy of less than 10 years based on the idea that they will likely die with the cancer but not from it. The recommendations are only for women who don’t have specific risk factors for breast cancer such as the BRCA1 and BRCA2 genetic mutations or a family history of the disease.
On Tuesday, breast cancer patient groups expressed alarm that the new guidelines — while not binding to doctors, hospitals or insurance companies — may lead too many women to skip life-saving screenings and provide an excuse for health plans to stop covering them as much as they currently do.
“We are worried about the message and confusion to the public when they see these new guidelines. The cutback on screening is falsely reassuring,” said Marisa Weiss, a doctor who is the founder and president of Breastcancer.org.
Mammograms, X-rays of breasts that have been used for more than a century to pinpoint irregularities in tissue, are credited with saving millions of lives by catching cancers at their earliest stages. Breast cancer is one of the leading killers of women in the U.S., with approximately 225,000 diagnosed each year and 41,000 dying from the disease. Over the years, many women have come to believe that the more screening and the more treatment the better.
But a number of new studies have questioned this idea.
In July, for example, a re-analysis of data from a pivotal paper based on women in the 1960s and ’70s in Sweden showed that screening could reduce deaths around 10 percent — rather than the 20 percent to 25 percent that had been originally claimed. And, in August, a study in JAMA Oncology found that the overall risk of dying after being diagnosed with socalled stage 0 or ductal carcinoma in situ cancer was 3.3 percent over two decades and that pursuing treatment beyond a lumpectomy did not affect survival.
The ACS is one of a number of organizations whose recommendations are hugely influential in how doctors treat their patients. The U.S. Preventive Services Task Force, an independent panel of experts whose members are appointed by the federal government, reaffirmed its view this April that women between ages 50 and 74 get routine screening once every two years. The American College of Obstetricians and Gynecologists still recommends that regular screenings begin at age 40.
That means that three different groups are now recommending three different ages — 40, 45 and 50 — when regular breast cancer screening should begin.
Nancy Keating, a doctor in internal medicine and primary care at Brigham and Women’s Hospital who wrote an editorial in JAMA accompanying the new guidelines, said the discrepancy shows how controversial the subject of mammograms can be.
“If there were an easy answer, they would all have the same conclusions,” Keating, who is also in the department of health care policy at Harvard Medical School, said in an interview, on the different groups’ recommendations. “It underscores the uncertainty.”