Dr. Anees Chagpar, associate professor of surgery (oncology) at Yale School of Medicine and director of The Breast Center at Smilow Cancer Hospital at Yale-New Haven, breaks down the new set of breast cancer screening guidelines issued by the U.S. Preventive Service Task Force (USPSTF).
The USPSTF has issued another set of recommendations for breast cancer screening. What are they?
The USPSTF recommendations for breast cancer screening are as follows:
Women between the ages of 40 and 49 should consult a doctor to individualize screening recommendations based on personal situation and risk
- For women between the ages of 50 and 75, screening mammography is recommended every two years
- For women over the age 75, there are insufficient data to make recommendations. Women should consult their doctors
Do the recommendations differ from previous ones and if so, how?
The recommendations of the USPSTF are similar to their previous ones, but differ somewhat from the new and former American Cancer Society (ACS) guidelines as well as current guidelines from the American College of Radiology. The former ACS guidelines recommended annual screening mammography; this is also the current recommendation from the American College of Radiology and several other societies. However, the new ACS guidelines are more in line with the USPSTF guidelines in their recommendation for screening every two years beginning at age 55.
Why is there yet another set of guidelines for mammograms?
We continue to evaluate the data in terms of risks and benefits. There is no question that mammography saves lives — it enables us to find cancers sooner, when they are smaller and more treatable. However, increasing data are emerging regarding the risks of mammography — the radiation exposure, unnecessary biopsies, and over-diagnosis — the concept that some small cancers may never have any meaningful impact on one’s longevity and may not require treatment.
How do the new recommendations affect women when they go to the doctor?
Hopefully, the recommendations affect women only in terms of having meaningful conversations with their doctors about risks and what tests are right for them. Women should not interpret the new guidelines as diminishing the importance of mammography. And insurers should continue to cover screening mammography every one to two years.
Do the guidelines match what you tell patients about screening?
Pretty much, although these guidelines don’t apply to most of my patients. Remember, these guidelines are only for women at average risk. That means if someone already has been diagnosed with cancer, has a genetic mutation or strong family history of breast cancer, or has symptoms such as a lump, bloody nipple discharge, or skin changes, these guidelines don’t apply.
What should women in their 40s think about in terms of screening?
Well, the data do indicate that screening mammography can find cancers in women in their 40s. Many of us have had patients who go for their first screening mammogram at the age of 40 and are found to have a cancer. So, it’s important for women in their 40s to talk to their doctors about their risks to determine when and how frequently they ought to be screened.
Breast cancer is less common for women in their 40s than women in their 60s. This is why screening is more efficient in the latter age category. But younger women tend to get more aggressive cancers, so it behooves us to find these as early as possible. It’s important for young women to know their risk and tailor their screening accordingly. And of course, if women get symptoms at any age, they should see their doctor.
What about women with a family history? Should they get more screening than is recommended?
The guidelines pertain only to women at average risk. So, if someone has a strong family history of breast cancer, she should talk to her doctor about what may be right for her. For example, women who have a BRCA gene mutation or a family history of such a gene mutation should likely be getting annual mammograms and annual MRIs. Women who have a family history of a first-degree relative who had cancer at a young age (<50) should consider starting screening 10 years earlier than the age at which their youngest relative was diagnosed with breast cancer.
However, not all family histories necessarily merit more aggressive screening. For example, my mother was diagnosed at the age of 74; and although I am at slightly increased risk due to the fact that I have a first-degree family history of breast cancer, given that there is no other family history, I would likely follow routine screening guidelines.
What else do women need to know about detecting or preventing breast cancer?
There are many things that women should keep in mind. In terms of detecting breast cancer, remember first of all, that mammography is the mainstay. For women with dense breasts, ultrasound may be a helpful addition to mammography but should not replace mammography.
Women should also know that the technology for mammography is improving dramatically. Three-dimensional mammography, called tomosynthesis, is a promising technology that allows the radiologist to analyze thin sections of the breast. It has been shown to improve detection and reduce call-back rates.
How can women determine and lower their risk?
Even without a family history, there are other factors that can increase risk. One can do a quick calculation of risk here. Note that this model (known as the Gail Model) is not perfect but has been used in many prevention trials. If someone has a five-year risk of more than 1.67, she would be considered high risk.
In terms of preventing breast cancer, women should remember that maintaining an ideal body weight, avoiding excessive alcohol, and minimizing exogenous estrogen exposure through things like hormone replacement therapy can all help to minimize risk. It’s also important for women to know their risk — know their family history, and seek the advice of genetic counselors if they are concerned about a genetic predisposition. Remember, however, that most breast cancers are sporadic and not related to a particular genetic mutation that may run in the family.
If a woman finds she has a higher-than-average risk, what can be done?
There are many things that can be done to reduce risk. First, talk to a doctor about the type and frequency of screening that is right for the risk. While this won’t prevent cancer, it can save lives by allowing us to find cancers earlier when they are most treatable.
Second, there are medications, such as tamoxifen, raloxifene, or the aromatase inhibitors that have been shown to also reduce risk by roughly 50% in women who are at high risk. If this is of interest, a woman should talk to her doctor or seek out a high-risk clinic to learn about risks and benefits of these medications.
Finally, prophylactic surgery may be of benefit. For women who are at very high risk, prophylactic mastectomy can reduce risk of developing breast cancer by 95%. Often this can be done with immediate reconstruction and the cosmetic results are very good. For women who have a BRCA mutation, prophylactic ovary removal can reduce risk of both ovarian and breast cancer. Again, a woman should talk to a breast and/or gynecologic surgical oncologist about these options to see if they are right for her.