Final USPSTF Guidelines Reduce Breast Cancer Screening, Cause Debate Among Oncologists

USPSTF Guidelines Breast Cancer Screening

Albert Siu, MD

Despite the initial controversy caused over 6 years ago, the US Preventive Services Task Force (USPSTF) has released a final version of its guidelines that stick to its initial assessment.

The guidelines state that women with an average risk of breast cancer should not start routine screenings until they reach age 50 and should then undergo testing every 2 years subsequent to the milestone. In standing its ground with the guidelines, the panel repeated its belief that although screening mammography is effective in reducing breast cancer mortalities among women between ages 40 and 75, the benefits do not sufficiently outweigh the risks for the broader screening programs previously recommended.

The new guidelines were published alongside the USPSTF's announcement in the Annals of Internal Medicine.¹The publication ran an editorial saying it was “time to douse the firestorm” concerning screening. Regardless, the overall reaction from the oncology community suggested the debate would continue.

“Although for many years the dogma was that women should have mammograms ‘once a year for a lifetime’ starting at age 40 years, current evidence shows that the balance of risks and benefits of screening, particularly among women in their 40s, warrants more nuanced decision making,” Christine Laine, MD, MPH, editor-in-chief of Annals of Internal Medicine, and colleagues wrote in the editorial.²“…The potential benefits of preventing breast cancer deaths are real, but the likelihood of those benefits is small and no definitive evidence shows that screening reduces total mortality.”

Contrasting the opinions expressed by the Annals of Internal Medicine, both the American College of Radiology (ACR) and the Society of Breast Imaging (SBI) released a joint statement stating that the recommendations would result in lethal consequences for thousands of women each year.

“A recent study in the British Medical Journal confirms that early detection of breast cancer via mammography is critical for improving breast cancer survival, regardless of therapy advances. Moving away from yearly screening in women 40-and-older endangers women, would cause needless death and disfigurement of women, and would simply not be good breast cancer screening policy,” said Debra Monticciolo, MD, FACR, chair, ACR, in the statement.

Murray Rebner, MD, former president of the SBI, said the USPSTF’s guidelines are “scientifically and methodologically flawed" and that the gSBI continues to recommend that women begin annual screenings starting at age 40.

The USPSTF guidelines apply to asymptomatic women who either do not have preexisting breast cancer or a previously diagnosed high-risk lesion, or who do not exhibit a higher risk level due to genetic mutations, family history, or a history of chest radiation at a young age.

The key recommendations, tailored to age levels, are these:

• 40-49 years:Recommends informed, individualized decision-making based on a woman’s values, preferences, and health history. (C recommendation)
• 50-74 years:Recommends mammography every 2 years. (B recommendation)
• 75 years and older:More research needed. Current science inadequate to recommend for or against. (I statement for insufficient evidence)

The US Department of Health and Human Services said the recommendations will not affect insurance coverage for mammography because of federal legislation signed in December 2015 that keeps benefits the same through 2017.

“Women 40 years and older enrolled in most health insurance plans will continue to be covered for screening mammography every 1 to 2 years without copays, coinsurance, or deductibles—just as they are today,” said Nancy C. Lee, MD, director, Office of Women’s Health at the US Department of Health and Human Services., in a statement. “If a woman is 40 years and older and her doctor determines that a mammogram is appropriate, she will not have to pay out of pocket.”

Heated debate over the recommendations would continue during legislative protections, said William T. Thorwarth, Jr, MD, FACR, chief executive officer of the ACR.

“This congressionally mandated delay will help providers continue to save tens of thousands of lives each year while the USPSTF recommendations and their creation process are vetted by breast cancer screening experts and lawmakers,” Thorwarth said in statement.

In expanding upon the USPSTF findings, Albert L. Siu, MD, MSPH, who chaired the panel, noted that the American Cancer Society (ACS) also has recognized that the benefits of mammography increase with age.

In October 2015, ACS updated its breast cancer screening guideline³to recommend women at an average risk of breast cancer should wait to undergo annual screening mammographies until they reach age 45. Additionally, after age 55, the guideline recommends shifting the schedule of undergoing a mammography to every other year.

Prior ACS recommendations, which were formulated in 2003, recommended that annual screening should begin at age 40.

“We hope this growing convergence among distinct organizations gives women and their healthcare providers confidence in the science that supports mammography screening,” said Siu, chair, Ellen and Howard C. Katz Mount Sinai Health System, professor, Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai.

Despite the objections raised by some in the oncology community, others expressed support.

Anees B. Chagpar, MD, associate professor of Surgery (Oncology), director, The Breast Center at Smilow Cancer Hospital at Yale-New Haven, said the new guidelines change the focus of screening.

“Women should know what their risk is,” Chagpar said in an interview with Targeted Oncology. “Women who are at high risk, for example, who have a genetic mutation that puts them at higher risk for developing breast cancer and who have a very strong family history of breast cancer, should really be talking to their doctors on when they should be starting mammography, and whether they should be having other tests, as well.”

“If you look at national trends and ask women, ‘have you had a mammogram this year?’ A lot of women forget; therefore, if you get a mammogram every other year, that’s probably just fine,” Chagpar said. “It’s not sending the message—and I hope that it doesn’t send the message—that mammograms aren’t important. They still are. It’s the best technique for finding cancers early when they are the most treatable, and the advent of screening mammography has truly been critical in the reduction in mortality that we have seen over the last several decades.”

In creating the final version of the recommendations, the USPSTF conducted a review of the science since its 2009 recommendation. The draft recommendation was available for public comment from April 21 to May 18, 2015.

References

1. Siu AL on behalf of the US Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement [published online January 11, 2015]. Ann Intern Med. doi:10.7326/M15-2886.
2. Laine C, Dickersin K, Mulrow C. Time to douse the firestorm around breast cancer screening [published online January 11, 2015]. Ann Intern Med. doi:10.7326/M15-3065.
3. Oeffinger KC, Fontham ETH, Etzioni R, et al. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society. JAMA. 2015;314(15):1599-1614.