Healthy Choices

Mammograms at 45: American Cancer Society changes breast cancer guidelines

A radiologist uses a magnifying glass to check mammograms for breast cancer in Los Angeles.
A radiologist uses a magnifying glass to check mammograms for breast cancer in Los Angeles. The Associated Press

Adding to the national debate over breast cancer screenings, the American Cancer Society issued new guidelines Tuesday advising most women to start annual mammograms later – at age 45 – and to get fewer over their lifetime.

By changing its long-standing recommendation that mammograms begin at age 40, the cancer society said it was taking into account new research, including a study from UC Davis that showed breast cancer screenings should be based on menopausal status, not age. The study found that women who had not gone through menopause were more likely to develop aggressive tumors.

The new guidelines, the cancer society’s first since 2003, now call for women to have annual mammograms from ages 45 to 54, then switch to every two years until age 74, if they have an average risk of breast disease. The guidelines also advise that breast exams, by a medical provider or a self-exam, are no longer recommended.

But, the cancer society noted, the recommendations are intended for those with average risk. Women with a family breast cancer history, genetic markers or other risk factors can decide to start mammograms earlier or continue them annually beyond the recommended age.

For many women, deciding when – and how often – to get a mammogram to detect breast cancer has become confusing, as well-respected medical groups offer differing guidelines. Until Tuesday, two of the most respected health groups had recommendations that differed by 10 years. While the cancer society advised women to get tested annually starting at age 40, the U.S. Preventive Services Task Force said they could wait until age 50, and then get tested only every other year.

Breast cancer survivors and advocates offered mixed reactions Tuesday to the new cancer society recommendations.

“I absolutely do not agree with them,” said Cindy Love, executive director of Albie Aware, a Sacramento-based breast cancer survivors network. “When you sit on my side of the desk and you get calls from women – some in their 30s and 40s – who’ve been newly diagnosed, I don’t think it’s safe to wait. (A mammogram) is the only thing we have.”

Donna Scully, an Elk Grove cosmetics saleswoman, was diagnosed at age 57 after a yearly mammogram caught a sizable tumor. She said she can’t imagine scaling back on yearly breast checks.

“I’d be dead if I’d gone in two years later,” said Scully, who underwent a double mastectomy and radiation. Now 60, Scully is taking an oral chemotherapy drug to fight a recent cancer recurrence.

Others, such as longtime breast cancer advocacy group Susan G. Komen for the Cure, expressed concern that the later-age recommendation might deter insurance companies from covering annual mammograms.

Although health care providers are not required to follow the cancer society’s recommendations, the changes could potentially “lead to reduced accessibility and coverage for health screenings,” said Kelly MacMillan, executive director of the Sacramento Valley chapter of Susan G. Komen for the Cure, in an email.

MacMillan also dislikes the advice that clinical breast exams – the manual check for tumors by health care providers, usually during a woman’s annual wellness check – are no longer necessary. “Clinical breast exams are not invasive and we know that often they are the only form of breast screening available to younger women, the underserved and those in rural areas of Northern and Central California.”

Others welcomed the cancer society’s shift.

“It’s more precise; it’s based on more recent data. They rigorously looked at the data and drilled it down,” said Dr. Kurt Snipes, a public health official and director of the California Cancer Registry. Starting at age 45, he noted, is where the increased benefit of yearly mammograms outweighs the potential harm a woman might undergo if she was “falsely diagnosed or overdiagnosed with a small, in-situ tumor that wasn’t going to turn into full-blown breast cancer.”

For women in the decade from 44 to 54, “It’s the 10-year window where the value of the mammogram far outweighs any of the harm that might result. The data shows you’re minimizing the false positives, you’re going to catch more tumors that are treatable,” said Snipes, who serves as a volunteer board member of the American Cancer Society in California.

And, he noted, women are still encouraged under the guidelines to consult with their doctors about their options.

In San Francisco, the nonprofit Breast Cancer Action, an advocacy group, said the changes are long overdue. “After years of relentlessly promoting annual mammography for women age 40 and older and overstating the benefits of early detection, the ACS is finally starting to follow the evidence on the limitations of routine breast cancer screening for women at average risk,” executive director Karuna Jaggar said in a statement.

The American Cancer Society’s changes are partly tied to a new UC Davis study, also released Tuesday, which looked at data from 15,440 U.S. women, ranging in age from 40 to 85, who were diagnosed with breast cancer within a year or two of their mammograms. Their screening frequency was compared with their type of cancer based on three factors: tumor size (15 millimeters or larger), aggressiveness (stage II B or higher) and involvement of lymph nodes (positive or negative).

“We found menopausal status was a much better predictor of who benefits from screenings,” said Diana Miglioretti, a biostatistics professor with the UC Davis Department of Public Health Sciences, who conducted the research project at the request of the cancer society.

Her study found that women who haven’t gone through menopause – no matter their age – were more likely to develop aggressive cancers if they waited every two years for a mammogram. According to the research, that means premenopausal women should stay with annual screenings if they want to detect cancers at earlier stages when they’re more treatable.

On the flip side, women who were postmenopausal – whether that occurred in their 40s or later – didn’t show any statistical increase in aggressive, later-stage breast cancer whether they had annual screenings or biennial screenings.

The average age of menopause for U.S. women is 51.

“Our study provides another piece of evidence that biennial screenings – every other year – are safe for some women: namely, postmenopausal women,” Miglioretti said.

Miglioretti’s research was conducted through her work as a co-leader with the Breast Cancer Surveillance Consortium, a research group affiliated with the National Cancer Institute to conduct research into breast cancer screening and pathologies. The current study was based on data from a San Francisco/Marin County mammography center, plus others in Washington state, Vermont, New Hampshire and North Carolina.

Breast cancer is the No. 2 cause of cancer deaths for U.S. women. In 2015, an estimated 231,840 women will be diagnosed with breast cancer, according to the American Cancer Society.

Claudia Buck: 916-321-1968, @Claudia_Buck

New guidelines

Here are the revised guidelines for women with an average risk of breast cancer:

  • Most women should begin yearly mammograms at age 45, rather than 40 as previously recommended.
  • At age 55, women should switch to having mammograms every other year, although those who want to continue yearly mammograms should do so. Mammograms every two years should continue until age 74 for those in good health.
  • If women prefer to start screening as early as age 40, they should be able to do so. Women should talk with their health care provider about when to begin screening.
  • Breast exams, either by a medical provider or self-exams, are no longer recommended.

Source: American Cancer Society

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