In major shift, American Cancer Society scales back mammogram recommendations

The American Cancer Society, one of the nation's most trusted voices in ongoing debates over mammograms, issued guidelines Tuesday reflecting a major 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 screenings 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 American Cancer Society president, said 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 the guidelines 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,' he said.

The approach outlined by the ACS calls for women starting yearly screening at age 45 and then transitioning to screening every two years starting at age 55. It also recommended 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 or a family history of the disease.

Tuesday, breast cancer patient groups expressed alarm that the new guidelines — while not binding on doctors, hospitals or insurance companies — may cause too many women to skip lifesaving screenings and provide an excuse for health plans to stop covering them as much.

Judy Salerno, president of Susan G. Komen, said she's 'concerned that they have the potential to lead to reduced accessibility to and coverage for health screenings from both private and public insurers.'

The ACS guidelines also include a recommendation against routine clinical breast examination, a major change for many women who are used to getting one during their annual physical exams. Wender said that doesn't mean the organization is asking physicians to stop.

'What the guidelines are saying is that it is mammography that really reduces the risk of breast cancer because it finds them before anybody can feel them,' he said.

The ACS' updates come at a time when cancer experts are rethinking the very definition of cancer. Thanks to advances in genetic testing, blood-based markers and digital imaging, cancer is being diagnosed earlier than ever and there's a radical new recognition that there are subset tumors that are detected but may never grow enough to be harmful.

Mammograms, X-rays of the breast that have been used for more than a century to pinpoint irregularities, are credited with saving many millions of lives by catching cancers early. Many women have come to believe that the more screenings and the more treatment, the better.

But when, and how often, remain questions.

The U.S. Preventive Services Task Force, a panel of experts appointed by the federal government, reaffirmed its view this April that women between 50 and 74 get routine screenings once every two years. The American College of Obstetricians and Gynecologists recommends regular screenings at 40.

That means now the three different groups are recommending three different ages — 40, 45, and 50 — when regular screenings should begin.

In looking at the ACS' explanation, Daniel Kopans, a professor of radiology at Harvard Medical School, noted that the 'emotional effects' of being recalled to undergo more testing was one reason given. That's because mammograms can sometimes show areas that look like masses but later test to be nothing.

'They seem to have wanted to account for the inconvenience of a recall from screening to suggest that some women might prefer to chance an avoidable death for a reduced chance of being recalled for a few extra pictures or an ultrasound,' he said.

Kopans said he still recommends yearly screenings starting at 40.

Q&A: Cedar Rapids doctors explain mammograms are key for early detection

Breast cancer is the leading form of cancer in Iowa women and has the second-highest mortality rate, according to the 2015 Iowa Cancer Registry. In 2015, more than 26 percent of new cancer cases in women — or 2,250 cases — are estimated to be breast cancer cases. About 390 women in the state are expected to die of the disease this year, or 13 percent of all cancer deaths in women.

The Gazette spoke with Dr. Vincent Reid, a surgical oncologist at Mercy Medical Center's Hall-Perrine Cancer Center, and Dr. Arnold Honick, UnityPoint Health — St. Luke's Breast and Bone medical director and a radiologist with Radiology Consultants of Iowa, about the recommendations and what women should do.

Different organizations have different recommendations, whether that's how frequently women should get mammograms or when they should start. What are they supposed to do with all of this conflicting information?

Reid: The most important thing to do as a patient is to have a relationship with a primary care physician to help you sort through this quagmire of recommendations. The U.S. Preventive Services Task Force has even different recommendations than these. As a patient, to respond every time one of these comes out, it would be very frustrating, and you would end up in a place of confusion. ... If you have that relationship with a primary care doctor and get an annual exam, they can help guide you through the necessary imaging.

Honick: There's a variety of sources — the Society of Breast Imaging has even created endtheconfusion.org, which has a short video and talks about risk factors and when women should get screenings. The National Cancer Institute has some as well. It can be hard to piece it together. You need to look at risk factors like family history.

Why would less screening be more beneficial?

Honick: What (the American Cancer Society is) doing is weighing risks and benefits. The idea of finding something, bringing the patient back, the anxiety and cost of it, and it's nothing. But we have a recall rate of about 10 percent or less. Only 2 percent of those we biopsy. And of those we biopsy, about 30 to 40 percent have breast cancer. The other part of the picture is over diagnosis. A cancer may never cause death ... so it may not need as aggressive treatment.

Will your organization change or reconsider its practices?

Reid: We look at evidence and guidelines to consider how to incorporate the information into how we take care of patients. Mammograms are the most important thing when it comes to early detection of breast cancer. We can debate when to start them and when we can get the biggest bang for the buck, but it's still necessary imaging.

Honick: This has created even more confusion. I believe radiologists and women's centers will continue annual exams starting at 40. You can always ask to talk with a doctor.