In this slideshow, various clinical guidelines on breast cancer screening are summarized, including the ACP's recent recommendations that have come under some scrutiny.
According to the National Cancer Institute, breast cancer is the second most common cause of cancer-related death among women in the United States. Screening can help to find cancer at an early stage, when treatment is most effective and cure is more likely. Key professional organizations have published various clinical guidelines regarding when and how often to screen women at average and high-risk for breast cancer. However, their recommendations are not always concordant. The American College of Physicians (ACP) recently released new screening guidelines for average-risk women that have come under some scrutiny. This slideshow highlights the ACP’s updated guidance as well as several other breast cancer screening recommendations from key healthcare organizations and societies.
1. New ACP Breast Cancer Screening Guidelines for Average-Risk Women. On April 9, 2019, the ACP released new screening guidelines for women at average risk for breast cancer. According to the recommendations, women between the ages of 50 and 74 years with no history of breast cancer, high-grade lesions, genetic mutations (such as BRCA1/2 mutation or others), familial breast cancer syndrome, or childhood chest radiation therapy should undergo screening mammogram every other year. Both the American College of Radiology (ACR) and the Society of Breast Imaging (SBI) have scrutinized these guidelines, issuing in a joint statement on April 8, 2019, that they “may result in up to 10,000 additional, and unnecessary, breast cancer deaths.” (Source / Source)
2. ACP Guidelines: Discuss Risks/Benefits With Patients. In addition to the new breast cancer screening guidelines for average-risk women ages 50 to 74 years, the ACP also recommends that average-risk women ages 40 to 49 years discuss the risks and benefits of starting to get mammograms before age 50 years with their healthcare provider due to the potential harms in this population of women. The ACP also recommends that breast cancer screening be discontinued in women ages 75 and older and in those with a limited life expectancy of 10 years or less. Additionally, the guidelines recommend that clinical breast exams in average-risk women of any age should not be utilized. (Source)
3. ACR and SBI Continue to Recommend Annual Breast Screening. On April 4, 2018, the ACR and SBI published new breast cancer screening guidelines, affirming their stance that screening initiation start at age 40 for all women, following a risk assessment at age 30. The rationale for the risk assessment is to determine the need for earlier screening, especially in women with a personal history of breast cancer who would benefit from breast cancer screening with MRI. (Source)
4. ACR/SBI Guidelines Classify Black Women as High-Risk for Breast Cancer. Guidelines from the ACR and SBI published in April 2018 classify black women as being high-risk for breast cancer. They state that, compared with non-Hispanic white females, non-Hispanic black women have a 39% higher rate of death from breast cancer. In addition, black women harbor more aggressive triple-negative cancers and have increased breast cancer mortality rates. As a result, the ACR and SBI recommend that black women undergo a risk assessment evaluation by at least age 30. (Source)
5. USPSTF Recommendations for Screening Average-Risk Women. The US Preventative Services Task Force (USPSTF) recommends biennial breast cancer screening mammography for women starting at age 50 and through age 74. Their recommendation is based on risk vs harms, and they concluded that screening women ages 40 to 49 may increase the risk for false positives and unnecessary biopsies. In addition, the USPSTF explained that disease mortality was lower in this group than in older women, and that early screening may result in overdiagnosis and overtreatment. (Source)
6. ACOG Focuses Breast Cancer Screening Guidelines on Patient–Provider Shared Decision-Making. In 2017, the American College of Obstetricians and Gynecologists (ACOG) published breast cancer screening guidelines for women at average risk of breast cancer. The ACOG recommends that screening mammograms be offered to women at age 40 and that screening begin no later than age 50. An emphasis is placed on patient–provider shared decision-making, in which patients and providers discuss the individual benefits and harms of initiating screening and determine whether screening every 1 or 2 years is appropriate. According to the guidelines, screening should continue until age 75; screening after age 75 should be discussed with the patient and determined based on health status and life expectancy. (Source)
7. ACR Breast Screening Recommendations for Women with a BRCA Mutation. Those with BRCA mutations, specifically BRCA1 or BRCA2 mutations, are more susceptible to breast cancer than women who do not harbor the mutation. Women with BRCA1 mutations carry a 50% to 85% lifetime risk of developing breast cancer, with BRCA2 mutations carrying a 45% risk. The risk for BRCA mutations is significantly increased among women of Ashkenazi Jewish descent. Currently, the ACR recommends diagnostic mammogram +/- digital breast tomosynthesis for women starting at age 30 who are genetically at risk for developing breast cancer or who have a > 20% lifetime risk score. In some cases, annual breast MRI starting between age 25 and 30 years may be recommended. (Source)
8. ACR on Early Breast Cancer Screening for Women With a History of Chest or Mantle Radiation. The ACR recommends early breast cancer screening for women with a history of chest or mantle radiation therapy, as they have a known increased risk for developing breast cancer. This risk is especially high approximately 8 years following therapy. The ACR recommends that women in this category undergo screening with a diagnostic mammogram +/- digital breast tomosynthesis starting at age 25 or 8 years after radiation therapy, whichever is later. Women treated during the first and second decades of life with > 20 Gy are at the highest risk for developing post-treatment breast cancers. (Source)
9. ACS Breast Cancer Screening Recommendations for High-Risk Women. The American Cancer Society (ACS) recommends that annual breast cancer screening with an MRI and mammogram start at age 30 for certain high-risk populations of women. This includes women with a > 20% to 25% lifetime risk, confirmed BRCA1 or BRCA2 mutations, a personal history of chest radiation between ages 10 to 30 years, or a personal or first-degree relative with syndromes such as Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome. These recommendations also apply to women with an unconfirmed BRCA mutation who have a first-degree relative with a known BRCA mutation. (Source)
10. ACS: Not Enough Evidence to Recommend Annual MRI Screening in Certain High-Risk Women. According to the ACS, there is currently not enough evidence to recommend annual breast screening with MRI in certain high-risk groups; however, if it is used, it should not take the place of mammogram and should be used as an adjunct. High-risk women in this category include those with mammogram-confirmed breast density (extreme or heterogeneous) and women with a history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH). In women with less than a 15% lifetime risk for developing breast cancer, MRI is not recommended as a screening tool. (Source)