Latest mammogram guidelines stress need for doctor/patient dialogue

The American Cancer Society's recent update of its guidelines, the first in more than a decade, changed the recommended age from 40 to 45 for some women to begin getting routine mammograms.

The ACS now recommends that women ages 40 to 44 should choose to begin annual screening “if they wish to do so.”

Experts say that wording represents a marked shift.

The ACS “did a really nice thing in stressing the role of patient preference and the need for it to be individualized rather than these cut-and-paste types of recommendations,” said Dr. Sandhya Pruthi, professor of medicine at the Mayo Clinic. “To understand that the future of breast cancer screening is a more personalized approach is huge.”

The guidelines urge providers to inform patients of the benefits and harms of screening at earlier ages.

Pruthi and others say that's already happening.

“There's a huge emphasis on shared decisionmaking between the patient and their physician,” said Dr. Laura Shepardson, associate director of breast imaging at the Cleveland Clinic. “It's really important for a patient and for the doctor to understand what the patient's values and preferences are.”

About 230,000 women in the U.S. are diagnosed annually with breast cancer, which ranks as the second-leading cause of cancer mortality among women, with more than 40,000 deaths annually. According to the ACS, 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 where the disease is not detected until Stage 4.

But some experts say recommending that women delay regular screening until ages 45 or 50 is a disservice to patients and makes it more difficult for younger women to get screened.

“Every woman should be able to get a mammogram at age 40, and if we're raising the age it may make it harder for them to do this,” said Dr. Mary Rosser, spokeswoman for American College of Obstetricians and Gynecologists.

Experts stress that early detection outweighs any cost, discomfort or anxiety. But routinely screening younger women has led to false positives and unnecessary treatment such as biopsies, radiation and even chemotherapy or surgery.

The ACS' updated guidelines say switching to every other year at age 55 makes sense because tumors in women after menopause tend to grow more slowly. Also, older women's breasts are usually less dense, so cancer is more visible on mammograms, said Dr. Kevin Oeffinger, chairman of the society's breast cancer guideline panel and director of the cancer survivorship center at Memorial Sloan Kettering Cancer Center in New York.

The ACS' guidelines follow advice similar to that proposed in 2009 by the U.S. Preventive Services Task Force, an independent body that makes recommendations on clinical preventive services and influences Medicare coverage. The panel recommended that women at average risk for breast cancer start getting mammograms after they turn 50 and then every two years.

The task force guidelines also take the ACS position on screening before 50. It recommends that screenings should be available for younger patients, who could make that decision after consulting with their physician.

And discussions with a physician may be the prudent route for patients, considering the ambiguity that exists over what is the right approach.

While the ACS guidelines suggest women begin screening at age 45 and the task force recommends age 50, the American College of Obstetricians and Gynecologists and the American College of Radiology asks women to begin screenings at 40.

The differing views are confusing for both doctors and patients.

“It would be nice to speak with one voice,” said Dr. Robert Wergin, board chair for the American Academy of Family Physicians. “Multiple different guidelines do create confusion.”

Shepardson said the ambiguity caused by differing guidelines make it even more important for providers to adopt the personalized approach when making such decisions.

“It's important to remember recommendations are just that—they are recommendations,” she said. “You can use them to help you make decisions, but it shouldn't be the absolute deciding factor without considering each patient's individual situation.”

And in fact, a study last year by the Powell Center for Women's Health at the University of Minnesota Medical School showed that cultural differences, especially within immigrant communities, factor into a woman's decision to be screened for breast cancer. These women, who take modesty into consideration when making their healthcare choices, already experience disparities in care.

Shepardson added that there has been discussion on creating a national consensus on breast cancer screening guidelines by the major stakeholders, but she was uncertain if any progress had been made toward those efforts.