Why is this so confusing?
You might think the advice on screening for breast cancer would have a clear-cut answer. However, so many factors play a role—a woman’s personal risk, the chance for false positives—that advisory groups hand out conflicting advice. Here’s what you need to know.
First of all, who writes the guidelines?
While numerous groups develop their own guidelines, the official ones come from the U.S. Preventive Services Task Force (USPSTF), an independent panel of 16 experts in primary care, prevention, and evidence-based medicine. The U.S. Department of Health and Human Services appoints the members, who serve four-year terms.
How have the guidelines changed?
Back in 2009, for the first time, the panel stated that women with an average breast cancer risk do not need annual mammograms until age 50. Before 2009, the recommended age was 40. The change sparked controversy, with advocacy groups claiming the new guidelines would lead to delayed breast cancer diagnoses and deaths. Despite the negative response, the USPSTF left the recommendations unchanged in the latest guidelines update, published in 2016 in the Annals of Internal Medicine.
The panel’s reasoning: Mammogram false positives have risks, too. In research involving records from more than 405,000 women who had mammograms from 2003 to 2011, false positives were particularly common in younger women: 12 percent of women ages 40 to 49 who had regular screenings experienced a false positive. Another study found that 61 percent of women who have annual mammograms beginning at age 40 experience at least one false positive by age 50. Limiting testing to every other year cuts the rate of false positives to about 42 percent.
False positives can lead to additional painful tests, potentially risky procedures, and patient anxiety. There is also concern over radiation exposure and potential overdiagnosis, in which doctors detect types of breast cancer that would have never been harmful.
Though the guidelines state screening does reduce mortality from breast cancer in women 40 to 74, the cancer is rare enough in women between the ages of 40 and 49 that they’re the least likely to benefit from screening (and more likely to suffer harm from false positives). Mammogram benefits are greatest in women ages 60 to 69. (There isn’t adequate evidence to determine if women 75 and older benefit from routine screening.)
“Screening mammography has been proven over and again to reduce breast cancer mortality in all women ages 40 and beyond,” explains Richard Reitherman, MD, PhD, medical director of breast imaging at MemorialCare Breast Center at Orange Coast Medical Center in Fountain Valley, California. “This is simply a function of the cancer axiom that earlier diagnosis leads to reduced mortality (death) and morbidity (less treatment, especially chemotherapy).”
However, he says, the application of any screening test is based on the probability of being diagnosed versus the direct risk of having the test and the consequences of needing subsequent testing, he explains. The women who end up with something suspicious on their mammogram have to get further tests to confirm or rule out cancer, which can include additional mammograms, breast ultrasound, and biopsy, says Dr. Reitherman. “A small number of these women will be recommended to have a biopsy,” he says. “Most of this group will not have breast cancer and can be confident in that result.”
What if I am at higher risk?
The age guidelines do not apply to women who have specific breast cancer risk factors, such as BRCA1 or BRCA2 genetic mutations or a family history of the disease. They also do not apply to women who notice symptoms, such as a lump—in this case, see your doctor right away. Here’s why these women are grateful for their BRCA diagnosis.
For women with dense breast tissue, not only is their risk for cancer slightly elevated, spotting it with a traditional mammogram is tricky. That’s why doctors recommend ultrasound or—for women with extremely dense breast tissue—MRI screening.
What do other groups say?
The American Cancer Society recently changed its recommended age at which to start getting annual mammograms to 45 (from 40). It suggests women continue yearly mammograms until age 55, at which point the society suggests shifting screenings to every other year. The American Congress of Obstetricians and Gynecologists suggests regular screenings beginning at age 40 until age 75, at which point the patient and her doctor can discuss whether to continue.
Does insurance still cover women 40 and older?
The Affordable Care Act and private insurers tend to follow the USPSTF and the U.S. Human Services and Resources Administration recommendations, reports the Kaiser Family Foundation, which means women with an average risk of breast cancer can get coverage for mammograms at least once every two years until the age of 74. There are also programs that provide low-cost or free mammograms for women who qualify, such as the National Breast and Cervical Cancer Early Detection Program.
So, what about MY next mammogram?
Talk to your doctor about your risk factors. If you have an average risk of breast cancer and are under age 50, you and your doctor should decide together what’s right for you. If doctor visits or tests make you nervous, waiting until you’re 50 to begin regular mammograms might be the best option. On the other hand, if you’re comfortable with yearly mammograms—and the risk of false positives—you may prefer annual mammograms out of vigilance.
But remember that regardless of age or when you had your last mammogram, any irregularities or suspicious symptoms, such as a lump on your breast, always merit a doctor visit.