The American Cancer Society (ACS) says women with an average risk of breast cancer should get an annual mammogram beginning at age 45. By age 55, the frequency should decrease to every other year.
The U.S. Preventative Services Task Force, an independent panel of health experts, issued recommendations in January that called for women between the ages of 55 and 74 to get a mammogram every two years.
And in August, research underwritten by the National Cancer Institute indicated that breast cancer screening recommendations be tailored to patients based on their breast density. Under these recommendations, women 50 and older who are high risk likely would get an annual mammogram.
Confused yet? If so, you aren’t the only one.
This year, doctors will diagnose more than 246,000 new cases of invasive breast cancer, and for many of these women early detection could save their lives. Mammograms have been a powerful tool in our arsenal, helping us detect cancer early before it metastasizes or before more invasive and intensive treatment options become our only recourse.
But in recent years, controversy around who should get a mammogram and when has created a lot of confusion for patients. Depending on where a patient gets her information, she may decide to wait two years before she gets a mammogram, but this decision can have a huge impact on certain patient’s long-term prognosis if they are ultimately diagnosed with breast cancer. Though there are conflicting schools of thought around breast cancer screening, my general philosophy is why wait and take that risk?
The Challenges of Breast Cancer Screening Recommendations
My concern with many of the current breast cancer screening recommendations is that not only do they conflict, but in many cases they aren’t personalized to a patient’s specific risk factors.
The ACS recommendations, for example, are very broad, are not specific-based on breast density and don’t recommend an MRI for women with dense breast tissue. Early detection is more challenging for women with dense breast tissue, but they tend to benefit from MRIs used in conjunction with mammograms and breast ultrasound, an approach that sometimes can spot lesions a mammogram may miss. There are currently about 30 states in the country that have MRI screening guidelines for women with high-dense breast tissue (Florida is not one of them). Screening recommendations based on breast density vary from state-to-state because of local legislation, so the guidelines tend to be inconsistent, creating even more confusion.
In general, the guidelines we follow for breast density is screening via an MRI, but the problem we run into often is that because MRIs are not part of the standard guidelines many insurance companies won’t cover it.
What is covered and what isn’t in regards to breast cancer screening is usually based on the U.S. Preventative Services Task Force recommendations, which today say there’s inadequate evidence of the benefits of MRIs and that regular screening in women under age 50 leads to more harm than good: “In addition to false-positive results and unnecessary biopsies, all women undergoing regular screening mammography are at risk for the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to their health, or even apparent, during their lifetime (known as “overdiagnosis”),” the task force says.
But most of us in the oncology world really question these recommendations. As a general rule, we continue to recommend annual mammograms starting at age 40 for women of average risk. We see women in the 40-45 age group with breast cancer every day in our clinic, and just as many women over age 55 whom we know that if they wait two years to do another mammogram, they likely could have more advanced stage disease.
What Women Can Do
Mammograms tend to pick up between 80-85 percent of breast cancer, but it’s still important for women to have a good understanding of what their breasts feel like. Though some organizations discourage breast self-exams as an early detection tool, my view is that patients have nothing to lose from doing them. If they don’t, they’ll never know what their normal or abnormal is.
Women in high-risk groups, including those with a family history, dense breast tissue or previous abnormal breast findings, should be even more proactive. These women need to be diligent about doing breast self-exams and annual mammograms. For some high-risk groups, preventative endocrine therapy or chemoprevention drugs like Tamoxifen also may be effective ways to lower their breast cancer risk.
Previous history of ovarian, triple negative or bilateral breast cancer may be indications for genetic testing, as well. For patients in this category, I’d urge their primary care providers and gynecologists to get as full and as thorough a family history as possible before ordering testing. In many cases, it’s best to refer these patients to a genetic counselor who can do a risk assessment that will empower these patients to be more proactive about their future care.
In spite of conflicting screening recommendations, each woman will have to make the best decision in consultation with her health care provider. Screening recommendations seem to keep changing every year, but a good rule of thumb for patients is to talk to their primary care physician or gynecologist for direction about how often to get a mammogram. Review the recommendations with your health care provider, but also understand that not every patient will fall neatly into the categories outlined by these organizations and that there may be cases where a patient needs a different type of screening or additional screening.
The guidelines keep changing, but patients and their doctors have to weigh their individual risks and the potential risk and benefit of each test. That is why it’s so important screening be tailored to each individual. Doing so likely will lead to more clarity for women with a low-to-average breast cancer risk and earlier detection for patients with the highest risk.
By Nikita Shah, MD
Nikita Shah, MD, serves as the medical oncology team leader for the Breast Cancer Specialty Section and medical director of the Cancer Risk Evaluation Program at UF Health Cancer Center — Orlando Health, where she has been a member of the medical team since 1999. Dr. Shah earned her medical degree from Baroda Medical College in India and completed an externship in the emergency department at Methodist Hospital in Indiana. As a medical student, Dr. Shah had the highest annual score in forensic medicine and received an award as an outstanding medical student.
She completed a residency in internal medicine at St. Francis Hospital in Evanston, IL, and a fellowship in hematology/ oncology at Northwestern Memorial Hospital in Chicago.
Dr. Shah is a member of numerous societies, including the Florida Medical Association, American Society of Clinical Oncologists, American Medical Association and American College of Physicians.