Task force: Mammograms an option at 40, do more good at 50

The U.S. Preventive Services Task Force's newest breast cancer screening guidelines reaffirm their 2009 recommendations that drew the ire of leading medical organizations.

The government task force's guidelines, published in the Annals of Internal Medicine on Monday, again recommend routine mammograms once every two years for women between the ages of 50 and 74 at average risk for breast cancer. Forty-something women could begin biennial screenings if they choose, the task force said, finding the tests at that age held a “small net benefit.”

The independent panel found “insufficient” evidence to determine the harms and benefits of mammograms for women 75 and older.

Women in their 60s are the most likely to avoid dying from breast cancer thanks to mammograms, but there's clearly enough benefit for the average woman to start at 50, the task force found.

Patient advocacy and medical groups have decried those recommendations since they were first made nearly seven years ago, believing they could discourage younger women from getting screened.

An estimated 230,000 women in the U.S. are diagnosed with breast cancer each year. Breast cancer is the second-leading cause of cancer mortality among women, with more than 40,000 deaths annually. According to the American Cancer Society, women whose cancer is detected at Stage 1 have a 100% rate of survival over the first five years after initial diagnosis compared with 22% among those whose cancer is not detected until Stage 4.

The task force contends the value of screening increases with age, and that routine screening before age 50 increases the risk of a false positive result, which could lead to unnecessary and often costly procedures and treatment. After menopause, tumors tend to grow more slowly and women's breast tissue becomes less dense and easier for mammograms to penetrate.

“In addition to false positive tests and unnecessary biopsies, all women undergoing regular screening mammography are at risk for the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not cause them harm during their lifetime,” said Dr. Kristen Bibbins-Domingo, task force vice chair, in a video released Monday.

The U.S. Preventive Services Task Force released these new guidelines, which are largely just a rewording of the 2009 standards, after announcing last spring that they were being reconsidered.

The group is just one of several professional organizations that makes recommendations.

The American Cancer Society updated its guidelines last October to call for women aged 45 to begin receiving annual mammograms until age 54, transitioning to biennial screening after 55. The ACS released a statement underscoring the importance of screening, regardless of the differing opinions. It stressed the importance of improving access to the one-third of women who are not regularly screened.

The American College of Obstetricians and Gynecologists recommends annual screenings begin at age 40, a position also taken by the American College of Radiology.

ACOG encourages women to discuss with their doctor their family history of cancer and risk factors such as being overweight.

"Moreover, it is essential that physicians counsel women about the potential consequences of mammography, including false positives," ACOG President Dr. Mark DeFrancesco said in a statement.

Dueling guidelines mean "some people get so confused they don't get screened at all. Some are too anxious or afraid not to do more, and it may not be better for them," said breast cancer specialist Dr. Laura Esserman of the University of California at San Francisco. "Maybe we should be screening in a new way."

Esserman leads the first-of-its-kind Wisdom study that soon will begin enrolling 100,000 women to test whether tailoring screening to someone's individual risk is better than age-based mammograms. Women given annual mammograms starting at 40 will be compared with others assigned more or less frequent screenings, starting at different ages, based on in-depth risk assessments.

The Affordable Care Act mandates coverage of preventive tests if the U.S. Preventive Services Task Force finds evidence supporting the test has a B or higher grade.

Because the panel gave screening before age 50 a C grade, some experts worry women will be scared off from the test because of the out-of-pocket costs they might incur.

But lawmakers overrode the task force recommendation, passing legislation requiring HHS to continue to cover the tests. Last month, Congress once again intervened after a draft of the recommendation in April indicated no change to the 2009 guidelines. Lawmakers added a two-year provision to the omnibus spending bill requiring HHS to recommend mammograms for women starting at age 40.

Still, worries remain that the task force recommendations could be adopted by HHS after 2018. ACOG plans to meet with stakeholders later this month to craft national guidelines.


Steven Ross Johnson

Steven Ross Johnson has been a staff reporter for Modern Healthcare magazine since 2013 and covers issues involving public health and other healthcare news. Johnson has been a freelance reporter for the Chicago Tribune, Progress Illinois, the Chicago Reporter and the Times of Northwest Indiana and a government affairs reporter for the Courier-News in Elgin, Ill. He received a bachelor's degree in communications from Columbia College in Chicago and a master’s degree in journalism from the Medill School of Journalism at Northwestern University.

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