Making Sense of the New Breast Cancer Screening Guidelines

Making Sense of the New Breast Cancer Screening Guidelines

It’s been an ongoing debate: Just when should a woman start having mammograms, and how helpful are they in detecting cancer? The American Cancer Society (ACS) has updated their guidelines to say that mammograms should happen later, and less frequently – a big change from previous ACS recommendations. We asked Sharecare Chief Medical Officer Keith Roach, MD, to explain.

What are the new recommendations, and what’s the biggest change?
Previously the ACS has stated that mammograms should start at age 40. Now they’re saying women should have them annually starting at age 45, and biannually starting at age 55. [The recommendations go on to say that] women should still have the opportunity to screen earlier—or every year—if they choose.

Isn’t that confusing?
I think they’re trying to allow for different patients and providers to have some flexibility so that an individual woman can make her own decision. In other words, if you feel strongly that you should have [mammograms] yearly, and at an earlier age, then you should.

Why do screening guidelines seem to change so often?
A little of it has to do with new evidence that gets published, and a little has to do with balancing the viewpoints of different groups. The US Preventive Services Task Force [USPSTF], whose guidelines say mammograms should begin at age 50, probably sticks most closely with the evidence. The ACS is being a little more aggressive in its recommendations, while still staying close to the published evidence. They’re trying to balance their desires to reduce cancers with the results of published evidence.

So who’s right?
There is no right answer. We can never know a single right decision for an individual woman. [That’s because] breast cancer isn’t one disease – it runs on a spectrum from benign to aggressive. There are indolent breast cancers, which are slow growing, and kind of mind their own business. And there are others that are very aggressive. The fact is that some breast cancers cannot be prevented with a screening program. For example, some breast cancers in young women, we can’t catch with screening. Occasionally we get lucky, but we often miss them.

What should a woman do?
A woman needs to see her doctor. She needs to explain her preferences. And she needs to understand the downsides of screening. The downside isn’t cost in dollars, or radiation. The downside is false positives. A mammogram may turn up something that looks like cancer but isn’t. We may end up putting a woman through a lot of expense and pain to prove that she didn’t have cancer in the first place.

Depending on how worried she is, she may decide she wants to be as aggressive as possible and start at age 40. Or she may decide to start at 50 and have it every other year. They’re both reasonable options.

It also depends on her risk. These guidelines are meant for women with average risk. If she has a family history of breast cancer, she may want to go for more intense screening.

The new recommendations also say clinical breast exams (in a doctor’s office) aren’t necessary. Why?
No studies have ever shown CBEs to be effective. By the time we can feel something with our fingers, if it’s cancer, it’s too late – and if it isn’t cancer, it doesn’t matter.

If you are getting a mammogram, though, it’s still a good idea to have a CBE, because it gives the doctor more info to go on.

What about breast self exams?
Quite a few studies on them have been done, but the benefit has never been proven. And they are not helpful with aggressive cancers.

What advice would you give your wife in light of the new recommendations?
My wife is 50 and gets screened every year. She doesn’t get particularly worried about the risk of false positives. What I tell my patients is, if you get a call back [after a mammogram], don’t freak out. Roughly 90% of false positives turn out OK.

Medically reviewed in June 2019.

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