Last week the American Cancer Society (ACS) released new breast cancer screening guidelines. There has been mixed reaction to these guidelines, which recommend less screening – mammography starting at a later age (45 years old) and less frequent (every two years after age 55). Those who are mammography skeptics applaud this ‘less is more’ approach. But those who feel early detection is the best way to prevent deaths from breast cancer, are defending that annual mammography from age 40 on is best. Yet another battle in the mammography war has started!
With the increased emphasis on personalized medicine, the new guidelines can be viewed as a small step in that direction. Not a ‘one-size-fits-all’ recommendation, but tailored to the patient’s age. This is reasonable. Yet the ACS acknowledges that annual screening yields a better mortality reduction than biennial and that all women over 40 should have access to annual mammograms. How is that going to work? Guidelines are supposed to guide – these leave it up in the air.
What are breast imagers supposed to tell the over-55 patients? Come back in 1… or 2 years? Or not give any recommendation and leave it up to the patient and her physician to decide? What are the medico-legal ramifications? If a woman over 55 who adheres to biennial screening feels she could have had her cancer detected earlier, will she sue her doctor for not recommending annual? Will most women and physicians really have an in-depth discussion of the risks and benefits of screening on an individual level? The responsibility on the referring physicians will be great.
Probably most concerning is what will happen to women in their early 40’s? The incidence of breast cancers is rising in young women in North America and women younger than 45 years old account for 25% of the life years lost to breast cancer. Sure, breast cancer is faster growing in young women and harder to detect. But should we give up on trying to save those lives? With state-of-the-art improved technology, such as 3D mammography, the balance of harms and benefits is shifting. Fewer false alarms and improved cancer detection means we have a better chance of helping those women.
Another issue not addressed by the ACS guidelines is breast density. If women do not start mammography at age 40 they will not be aware of their breast density, and will not seek supplemental screening, such as ultrasound, if their tissue is dense. Such supplemental screening helps improve detection of invasive breast cancers – the lethal ones that need to be found and treated. Many states (24 at last count) have passed legislation requiring a woman be informed of her breast density and be offered supplemental testing if her tissue is dense. Such laws have been put in place for a reason: to improve the chances of a more equitable screening outcome for women with dense tissue to those fortunate enough to have non-dense tissue. More than half of young women have dense tissue. But so do many older women. Such legislation will backfire if women are not getting regular mammograms in the first place.
In this era of focus on personalized medicine, all women have a right to be informed and have their screening optimized. While the new ACS guidelines appear to be a more tailored approach, they have the potential to end up a mess. Many women may not end up getting the optimal screening they deserve.
Liane Philpotts, MD is a Professor at Yale University
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