1. First of all, who writes these guidelines?
The U.S. Preventive Services Task Force (USPSTF), an independent panel of 16 experts in primary care, prevention, and evidence-based medicine, is responsible for issuing the guidelines. The U.S. Department of Health and Human Services appoints the members, who serve four-year terms. Typically, under the 2010 Affordable Care Act, the panel’s recommendations must be offered as part of private insurance plans. In this case, however, they’re not. (More on that below.)
2. What’s so important about the new guidelines?
You may remember hearing buzz about the mammogram guidelines 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 this year’s guidelines update, published in the Annals of Internal Medicine.
The panel’s reasoning: Mammogram false positives have risks, too. In a study of 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 the radiation exposure and potential overdiagnosis, in which doctors detect types of breast cancer that would have never been harmful.
“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).”
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 confirmatory tests that turn out to be negative, he explains. The women who do not have a negative result are recommended for further confirmatory tests such as additional mammograms and breast ultrasound. “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.”
Though the new guidelines state screening does reduce mortality from breast cancer in women 40 to 74, those ages 40 to 49 benefit the least. The 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. These 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.
The guidelines also note that more research is needed to determine the benefits and risks of screening for women with dense breasts (which make it more difficult to detect breast cancer with a mammogram) and the benefits of 3-D mammography for certain women (some studies have found that this new technology, used with standard digital mammograms, may increase breast cancer detection rates by more than 40 percent).
3. 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, with no upper age limit.
4. Will this affect my insurance coverage?
When Congress passed the Affordable Care Act in 2010, it mandated that certain preventive services be provided for free if the USPSTF strongly recommended those services. However, in response to the 2009 updated guidelines, it included an amendment that insurers must follow the 2002 mammogram recommendations instead. This meant women 40 and older could receive mammograms, which count as preventive care, at no cost.
The updated guidelines won’t affect insurance coverage immediately. In anticipation of the task force’s update, Congress took preemptive action in December 2015 by passing a bill that requires private insurers to cover yearly screening mammograms for women age 40 and older without copays, deductibles, or coinsurance, through 2017. It is uncertain how the policies will change after 2017.
Some experts question the political involvement while certain advocacy groups, such as the Society of Breast Imaging (SBI), applaud it. “Women should have the opportunity to make informed screening choices and have insurance coverage for those decisions,” said SBI president Elizabeth Morris, MD, in a statement. “Clearly [members of Congress] agree that women ages 40 to 49, 50 to 74, and 75 and older who want annual mammograms, should be covered for, and have access to, these lifesaving exams.”
In an editorial, the USPSTF says “coverage decisions are the domain of payers, regulators, and legislators” and that the panel “cannot exaggerate our interpretation of the science to ensure coverage for a service.” Many groups, including the American College of Radiology and the Susan G. Komen Foundation, have lobbied Congress to continue offering free annual mammogram coverage.
5. 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.