USPSTF final recommendations on breast cancer screening
1. Task Force Publishes Final Recommendations on Screening for Breast Cancer
Women ages 50 to 74 should be screened regularly; women in their 40s should make an individual decision in partnership with their doctors.
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Video soundbites from Dr. Kristen Bibbins-Domingo, Vice Chair of the U.S. Preventive Services Task Force, available for download at http://www.dssimon.com/MM/ACP-mammography. Task Force members also available for interviews (see note below).
The U.S. Preventive Services Task Force published a final recommendation statement on screening for breast cancer following an in-depth review of the science on the benefits and harms of screening mammography, and a detailed review of input received from the public and health care professionals on its 2015 draft recommendation. The Task Force–an independent, volunteer panel of experts in evidence-based medicine–examined the evidence on women who were not known to be at increased risk of breast cancer. The recommendation statement, which is published in Annals of Internal Medicine, is made up of several recommendations addressing different age groups and screening methods, and is accompanied by an editorial on how its findings converge with guidelines from other organizations.
The Task Force confirmed that screening mammography is effective in reducing deaths due to breast cancer among women ages 40 to 74 years. The greatest benefit of screening mammography occurs in women ages 50 to 74 years, and these women get the best balance of benefits to harms when screening is done every two years. This is a B recommendation.
For women in their 40s, the Task Force found that mammography screening every two years can also be effective and recommends that the decision to start screening should be an individual one, taking into account a woman's health history, preferences, and how she values the potential benefits and harms. Women in their 40s who have a mother, sister, or daughter with breast cancer may benefit more than average-risk women by beginning screening before age 50. This is a C recommendation.
While the Task Force noted that screening mammography is effective in reducing deaths from breast cancer for women in their 40s, the likelihood of benefit is less than for older women and the potential harms proportionally greater. The most serious potential harm of mammography screening is unneeded treatment for a type of cancer that would not have become a threat to a woman's health during her lifetime; the most common is a false-positive test result, which often leads to additional tests and procedures and may lead to anxiety and stress.
Finally, the Task Force identified a number of areas where additional research is needed to better understand how screening might reduce breast cancer deaths. Specifically, the Task Force concluded that evidence is insufficient to determine the balance of benefits and harms in three important areas: the benefits and harms of screening women age 75 and older; adjunctive screening in women with dense breasts; and the effectiveness of 3-D mammography for the detection of breast cancer. Due to this lack of evidence, the Task Force is unable to make a recommendation for or against these services. These are I statements. The Task Force strongly encourages additional research in these areas and notes that women should speak to their doctors to determine what is best for their individual needs.
It's important to note that the Task Force does not make recommendations for or against insurance coverage; coverage decisions are the responsibility of payers, regulators and legislators. Legislators recently extended a guarantee that women who have private insurance, beginning at age 40, will not have a co-pay for their screening mammogram. The role and mission of the Task Force is to provide all people with the best available information about the current science of prevention to empower them to make informed decisions about their health and health care.
Note: For an embargoed PDF, please contact Cara Graeff. To interview someone from the Task Force, please contact Nicole Raisch or Hannah Changi at [email protected] or 202-572-2044.
2. False-positive mammography results common among younger women
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False-positive results and additional imaging are common among younger women and women with risk factors for breast cancer who are screened with digital mammography. Biopsy occurs less often and rates of false-negative screening results are low. The analysis is published in Annals of Internal Medicine and was used to inform updated clinical practice recommendations from the U.S. Preventive Services Task Force.
Clinical guidelines recommend a personalized approach to mammography screening that takes into account individual risk factors for breast cancer as well as the potential benefits and harms of screening. Researchers used registry data for more than 400,0000 women aged 40 to 89 to estimate rates of false-positive and false-negative digital mammography results and subsequent imaging and biopsies among a general population of women undergoing screening with digital mammography. They found that false-positives and recommendations for additional imaging were highest among women younger women, or those aged 40 to 49 years. These rates decreased with age. Rates of false-negative results were generally low. Risk factors for breast cancer, such as positive family history, previous biopsy, high breast density, and low body mass index for younger women, were associated with higher risk for false-positive result.
Note: For an embargoed PDF, please contact Cara Graeff. To interview the lead author, Dr. Heidi Nelson, please contact Amanda Gibbs at [email protected]ohsu.edu or 503-494-5640.
3. Biennial mammography screening starting at age 50 may decrease risk for radiation-induced breast cancer
Women with large breasts or breast augmentation may have greatest risk for radiation-induced breast cancer and breast cancer death.
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Starting breast cancer screening at age 50 and undergoing digital mammography every other year may reduce a woman's risk for radiation-induced breast cancer. Due to the frequency and dosing of radiation, women with larger breasts and breast augmentation may face greater risk for breast cancer and breast cancer death. The modeling study is published in Annals of Internal Medicine and was used to inform updated clinical practice recommendations from the U.S. Preventive Services Task Force.
Repeated digital mammography examinations expose women to ionizing radiation that can increase breast cancer risk. Researchers used a computer model to estimate distributions of radiation-induced breast cancer incidence and mortality from digital mammography, taking into considering screening frequency and dose variation among women. They found that annual mammography screening of 100,000 women aged 40 to 74 years might induce 125 breast cancer cases and 16 deaths but avert 968 breast cancer deaths because of early detection. Women with large breasts requiring extra views and higher-than-average radiation doses per view were found to be at increased risk, as were those with breast implants. Beginning screening at a younger age and undergoing annual screening were also associated with an increased risk.
Radiation-induced breast cancer incidence is small relative to the number of breast cancer deaths averted, but is not trivial, according to the authors. They say that women with large breasts who begin annual screening before age 50 have twice the risk for radiation-induced breast cancer than women with small or average-sized breasts because large breasts require extra views for a complete examination. Radiology practices should strive to ensure that large breasts are imaged with large detectors with the fewest numbers of views possible.
Note: For an embargoed PDF, please contact Cara Graeff. To interview the lead author, Dr. Diana Miglioretti, please contact Dorsey Griffith at [email protected] or 916-734-9118.
This issue contains the following reviews and modeling papers related to the final USPSTF Breast Cancer Screening Recommendations. Most of the following content is free,
Effectiveness of Breast Cancer Screening: Systematic Review and Meta-analysis to Update the 2009 U.S. Preventive Services Task Force Recommendation
Heidi D. Nelson, MD, MPH; Rochelle Fu, PhD; Amy Cantor, MD, MPH; Miranda Pappas, MA; Monica Daeges, BA; and Linda Humphrey, MD, MPH
Free content: http://www.annals.org/article.aspx?doi=10.7326/M15-0969
Harms of Breast Cancer Screening: Systematic Review to Update the 2009 U.S. Preventive Services Task Force Recommendation
Heidi D. Nelson, MD, MPH; Miranda Pappas, MA; Amy Cantor, MD, MPH; Jessica Griffin, MS; Monica Daeges, BA; and Linda Humphrey, MD, MPH
Free content: http://www.annals.org/article.aspx?doi=10.7326/M15-0970
Supplemental Screening for Breast Cancer in Women With Dense Breasts: A Systematic Review for the U.S. Preventive Services Task Force
Joy Melnikow, MD, MPH; Joshua J. Fenton, MD, MPH; Evelyn P. Whitlock, MD, MPH; Diana L. Miglioretti, PhD; Meghan S. Weyrich, MPH; Jamie H. Thompson, MPH; and Kunal Shah
Free content: http://www.annals.org/article.aspx?doi=10.7326/M15-1789
Collaborative Modeling of the Benefits and Harms Associated with Different U.S. Breast Cancer Screening Strategies
Jeanne S. Mandelblatt, MD, MPH; Natasha K. Stout, PhD; Clyde B. Schechter, MA, MD; Jeroen J. van den Broek, MS; Diana L. Miglioretti, PhD; Martin Krapcho, BS; Amy Trentham-Dietz, PhD, MS; Diego Munoz, PhD, MS; Sandra J. Lee, ScD; Donald A. Berry, PhD; Nicolien T. van Ravesteyn, PhD; Oguzhan Alagoz, PhD; Karla Kerlikowske, MD; Anna N.A.Tosteson, ScD; Aimee M. Near, MPH; Amanda Hoeffken, MPH; Yaojen Chang, DrPH, MS, MPH; Eveline A. Heijnsdijk, PhD; Gary Chisholm, MS; Xuelin Huang, PhD; Hui Huang, MS; Mehmet Ali Ergun, MSc; Ronald Gangnon, PhD; Brian L. Sprague, PhD; Sylvia Plevritis, PhD; Eric Feuer, PhD; Harry J. de Koning, MD, PhD; Kathleen A. Cronin, PhD, MPH
Free content: http://www.annals.org/article.aspx?doi=10.7326/M15-1536
The Effect of Treatment Advances on the Mortality Results of Breast Cancer Screening Trials: A Microsimulation Model
Jeanette Birnbaum, PhD, MPH; Vijayakrishna K. Gadi, MD, PhD; Elan Markowitz; and Ruth Etzioni, PhD