ACOG updates its mammography screening guidelines; stressing emphasis on shared decision making.

courtesy: CBS news

ACOG today released a committee opinion updating its guidelines on Breast Cancer Risk Assessment and Screening in Average-Risk Women. This replaces the Practice Bulletin Number 122, August 2011.

This recent update lays emphasis on joint decision making, involving the patient and her physician.

Women who are average risk for breast cancer should be offered her first screening mammogram at age 40. No additional benefits are gained by starting screening before age 40. If women have not begun screening in 40s, they should begin screening mammography by no later than age 50 years.

The physician should have detail conversation with the patients about potential benefits and harm. For women who begin screening in early 40s, the benefits derived are smaller as compared to women who are older. But, the women can make an informed decision and opt for regular screening or wait till they reach 50s.

Average risk women should undergo screening mammography every 1 or 2 years, based on shared decision. “Biennial screening mammography, particularly after age 55 years, is a reasonable option to reduce the frequency of harms, as long as patient counseling includes a discussion that with decreased screening comes some reduction in benefits,” says the bulletin. 

The screening should continue till 75 years of age. Screening past 75 years depends on individual patient characteristics like her general health and expected life span.

The U.S.Preventive Services Task Force recommends that women should start regular mammograms at 50, and that women in their 40s should make an individual decision about whether or not to screen. The American Cancer Society says screening should be offered starting at age 40, and outright recommends starting at 45. And the National Comprehensive Cancer Network, an alliance of major cancer centers, recommends starting at 40.                                    

Recommendations from various organizations compared. Adapted from ACOG Bulletin.

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The different recommendations stem from a desire of all these groups to balance the benefits and harms of mammography and the way these societies interpret the data.

Christopher Zahn, vice president of practice activities at ACOG says,” "All three [schedules] are reasonable approaches to take, a patient's preferences and values need to be an important part."

Harms of screening mammography are anxiety and distress, false positive results, unnecessary biopsy and surgeries and radiation exposure.

Based on limited or inconsistent scientific evidence, Breast Self-Examinations (BSE) are not recommended because there is a risk of harm from false-positive test results and a lack of evidence of benefit. Screening clinical breast examination may be offered to these average risk women after a detailed discussion about uncertainty of additional benefits and the possibility of adverse consequences of clinical breast examination. The frequency of screening clinical breast examination is every 1–3 years for women aged 25–39 years and annually for women aged 40 years and older are reasonable.

Screening clinical breast examination is an important part of evaluation of high risk women and women with symptoms.

It should be noted that all these recommendations apply to average risk women. Women who are high risk should follow different set of guidelines as advised by their physicians. The high-risk factors for developing breast cancer according to the bulletin are female sex and advancing age, family history, BRCA mutation, dense breast, nulliparity, older age at first birth, older age at menopause, younger age at menarche and receiving therapeutic ionizing radiations.

The full text of  committee opinion can be accessed here.