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Mammogram-screening guidelines for women of average risk

American College of Obstetricians and Gynecologists:
Every year, 40 and older

U.S. Preventive Services Task Force:
Every other year, ages 50 to 74
Consult with doctor, 40 to 49

National Breast Cancer Coalition:
Every other year, ages 50 to 74
Consult with doctor, 40 to 49

American Cancer Society:
Consult with doctor, 40 to 45
Every year, ages 45 to 54
Every other year, 55 and older

National Comprehensive Cancer Network:
Every year, 40 and older

Memorial Sloan Kettering Cancer Center:
Every year, 40 and older

American College of Surgeons:
Every year, 40 and older

___

Breast cancer-related symptoms that require attention include:

  • Lump, hard, irregular knot or thickening in the breast or underarm
  • Swelling, warmth, redness or darkening of the breast
  • Change in breast size or shape
  • Dimpling or puckering of skin
  • Itchy, scaly sore or rash on nipple
  • Pulling in nipple or other breast areas
  • Nipple retraction
  • Nipple discharge
  • New spot of pain

Source: Susan G. Komen and American Cancer Society

___

Special Coverage: Breast Cancer Awareness


For decades, enduring a mammogram was a rite of passage for women turning 40.

Absent symptoms or genetics that would trigger screening at an earlier age, women knew reaching the four-decade mark meant they’d soon face getting squeezed in a machine for their own good.

But evolving recommendations from the American Cancer Society and from an influential federal task force on preventive medicine now hold that it’s better to wait until age 45 or even 50 to start having routine mammograms.

That changing guidance and a related debate about how often women in different age groups should be screened with the breast X-rays can confound patients, for whom preventative screening is often only a first step in a dizzying array of options for breast cancer care.

“It can be really confusing even for their physicians,” said Gretchen Smith, a radiologist specializing in breast diagnosis and intervention with Sutter Medical Group of the Redwoods. “It’s a moving target.”

On one point, consensus exists among doctors, researchers and public health officials: Mammography saves lives and should be available to all women by age 50, if not earlier, to detect signs of a disease that affects one in eight women, killing more than 40,000 American women a year.

Locally, many health care providers still advise patients who are at normal risk for breast cancer to get baseline mammograms at age 40 and to have one every year or every other year thereafter.

Each cancer caught early, each additional life spared, makes any downsides of early screening worthwhile, they argue. Many national professional associations agree.

“I don’t think, in practice, there’s much controversy” about screening women of ages 40 to 49, said Yung Do, a radiologist with Kaiser Permanente in Santa Rosa. “I think most clinicians I talk to, in practice, we see enough breast cancers between that age group that we feel like there’s a lot of value in (screening) that age group.”

Guideline implications

But the shifting guidelines mean women and their health care providers must navigate conflicting advice in an area that already provokes apprehension and fear among patients. In addition, doctors like Smith, a strong advocate of starting mammograms at 40, can find themselves at odds with the facility where they work. Sutter Health, where Smith practices, recommends women generally wait until age 50.

The discrepancies could have implications for how much routine imaging insurance companies cover in the future.

Guidelines issued by the U.S. Preventive Services Task Force, an expert panel convened by the federal Agency for Healthcare Research and Quality, a division of the U.S. Department of Health and Human Services, provide the framework for preventive screening and treatment that American health insurers are required to cover at no cost to their clients.

That task force now says women should start screening mammograms at 50 and have them only every other year through age 74.

It said the “balance of benefits and harms” doesn’t pencil out in a way that suggests younger women should be screened.

“While screening mammography in women aged 40 to 49 years may reduce the risk for breast cancer death,” the panel said, “the number of deaths averted is smaller than that in older women and the number of false-positive results and unnecessary biopsies is larger.”

‘Harms’ in screenings

Mammogram-screening guidelines for women of average risk

American College of Obstetricians and Gynecologists:
Every year, 40 and older

U.S. Preventive Services Task Force:
Every other year, ages 50 to 74
Consult with doctor, 40 to 49

National Breast Cancer Coalition:
Every other year, ages 50 to 74
Consult with doctor, 40 to 49

American Cancer Society:
Consult with doctor, 40 to 45
Every year, ages 45 to 54
Every other year, 55 and older

National Comprehensive Cancer Network:
Every year, 40 and older

Memorial Sloan Kettering Cancer Center:
Every year, 40 and older

American College of Surgeons:
Every year, 40 and older

___

Breast cancer-related symptoms that require attention include:

  • Lump, hard, irregular knot or thickening in the breast or underarm
  • Swelling, warmth, redness or darkening of the breast
  • Change in breast size or shape
  • Dimpling or puckering of skin
  • Itchy, scaly sore or rash on nipple
  • Pulling in nipple or other breast areas
  • Nipple retraction
  • Nipple discharge
  • New spot of pain

Source: Susan G. Komen and American Cancer Society

___

Special Coverage: Breast Cancer Awareness

Among the “harms” of screening mammography are the frequency with which something suspicious turns up on an initial mammogram, but once the patient submits to additional breast imaging, she finds out there was nothing amiss after all. In other cases, a woman may advance to a needle biopsy and find out no cancer was present.

Reducing mammography also cuts back on exposure to low-dose radiation, which the American Cancer Society says is roughly equal to the background radiation most women experience in their lives over a period of seven weeks.

More concerning, the task force said, is the matter of “overdiagnosis,” where screening turns up a cancer that is treated even though, had it been left alone, it may never have proved invasive, life-threatening or even apparent.

In all of these cases, patients suffer unnecessary anxiety, in addition to whatever physical intervention occurs, the panel said.

The task force first retreated from its long-held recommendation for mammograms at 40 in 2009, sparking a national debate on the topic. The panel reaffirmed its recommendations in January, three months after the American Cancer Society changed its own guidelines.

The ACS now recommends mammograms every year from age 45 to 54, and every other year after that.

Both sets of guidelines relate only to routine imaging for asymptomatic women at average risk for breast cancer, as opposed to diagnostic mammography, which is ordered for patients with lumps, breast irregularities or other symptoms.

Women at high risk for breast cancer because of certain genetic mutations, family history or childhood exposure to chest radiation should be screened early, in most cases, as well.

Santa Rosa resident Laura Hall, 45, took the task force recommendations to heart.

She has no family history of breast cancer and no other reason to think she’s at particular risk. She eats well, exercises and drinks only moderately. And she has full health coverage, so mammography would be free.

But she’s heard the procedure, in which a woman’s breasts are pressed between two low-dose X-ray plates, is not pleasant, and she’s witnessed the anxiety and discomfort of two friends who were called back for follow-up imaging and, eventually, biopsies.

One friend, it turned out, had a cyst. The other, a benign tumor.

“Watching them go through that, and seeing the emotional roller coaster they went through, and then the stress on their body going through having the breast dug out, basically, it was hard to watch,” Hall said. “Why would I go through that, especially hearing that I can wait?”

On the mammogram

The introduction of routine mammography in the mid-1980s is credited with reducing breast cancer deaths by about one-third, according to the National Cancer Institute.

About 100 out of every 1,000 women who go in for screening mammograms are instructed to return for additional mammography, breast ultrasound, or both, according to the American College of Radiology and the Society of Breast Imaging.

Sixty-one of the 100 will have the extra imaging and be given the all-clear signal, while 20 of the 100 will be asked to return in six months for follow-up screening, the organization said.

Another 19 will undergo image-guided needle biopsies to determine if they have cancer. Five of those will be positively diagnosed.

The Society of Breast Imaging says one in six new breast cancer cases will occur in women between 40 and 49.

But use of screening mammography in that age group declined by about 10 percent in just the first three years after the federal task force floated the guidance of waiting until 50, according to a Harvard study.

Elizabeth Peralta, a breast surgeon with Sutter Medical Group of the Redwoods, said she’s worried mammography rates will continue to fall, along with the quality of women’s health, as younger women hold off on imaging and older women who adopt a biennial screening schedule lose track, and end up going less and less often.

“I’m seeing a lot of women who are going five, six years without a mammogram and then present with a palpable mass,” Peralta said. “Or when they finally do get screened, they’ve got a larger tumor.”

Win-win scenario

Advocates of early imaging say women are capable of understanding the implications of different mammogram findings if someone just takes time to explain. They say any anxiety women experience awaiting follow-up testing is short-lived if the results prove negative. If the result is diagnosis of cancer, then there’s comfort in catching it earlier than might otherwise have been the case, doctors said.

“The scenario is a win-win,” Peralta said.

One of her patients, a 40-year-old woman now in treatment, said she had never given any thought to having a mammogram even as she approached her 40th birthday earlier this year. Then her primary care doctor informed her that she “had graduated” to the age of cancer screening and should undergo a mammogram.

“The slip and slide came right after that,” said the woman, who did not want her name used because she hasn’t shared all of her medical information with family yet. “Everything just went down hill.”

Her first mammogram detected signs of cancer and led to a CT scan, then an MRI, then a biopsy. She’s now had part of her breast removed, a procedure called a lumpectomy, but is undergoing genetic testing and may have further surgery.

As a mother and grandmother, she’s eager to do what’s necessary to rid her body of the disease, she said.

Breast cancer “doesn’t run in my family, but I’m thankful that my doctor had me do a mammogram at 40,” she said.

Heredity factors in

More than 75 percent of new breast cancers occur among women without any family history, experts say, which is one reason those who espouse an early-and-often approach to mammography do so.

“If everybody in the United States switched to current task force guidelines, it’s anticipated there would be an additional 6,500 deaths from breast cancer per year,” said Laura Norton, a breast surgeon with St. Joseph Health’s Annadel Medical Group. “Not just increased incidences. Increased deaths.”

She was referencing an off-cited analysis published by the American Journal of Roentgenology in 2011 that assumed a compliance rate of about 65 percent, roughly the average rate of mammography use among U.S. women age 40 and older, according to the Centers for Disease Control and Prevention.

“Starting screening mammograms at age 40 and doing them every year should be the standard, and that is based on the fact that it will save the most lives from breast cancer, and no one really disputes that,” Norton said.

The American College of Obstetricians and Gynecologists is among those that still urge women to start screening mammograms at 40. But ACOG is partnering with the federal Health Resources and Services Administration to update recommendations for women’s preventive health care. A five-year process called the Women’s Preventive Services Initiative will address guidelines for mammograms in addition to other screening, as well.

In the meantime, Congress, at the urging of women’s health advocacy groups, last year approved a moratorium on implementing the new Preventive Services Task Force guidelines through the end of next year, ensuring insurance providers continue to cover the cost of mammograms for women in their 40s without any out-of-pocket expense, like co-pays or deductibles. Prior to that, lawmakers put language in the Affordable Care Act of 2010 requiring coverage of screening mammography according to the task force’s 2002 recommendations, which called for imaging at age 40.

But it’s unclear what will happen come 2018, when the task force’s updated guidelines can be implemented.

“I think there’s a lot of concern among the people who continue to recommend this annually,” Smith said.

You can reach Staff Writer Mary Callahan at 707-521-5249 or mary.callahan@pressdemocrat.com. On Twitter @MaryCallahanB.