Breast Cancer Screening: Four Key Points Cut Through the Chaos

Andrew M. Kaunitz, MD


May 01, 2019

This transcript has been edited for clarity.

Today I return to the persistently emotional topic of breast cancer screening. Recommendations from professional societies about screening in average-risk women vary with respect to starting age, stopping age, frequency of screening, and whether a clinical breast examination should be performed. A new guidance statement from the American College of Physicians (ACP)[1] assessed seven existing guidelines addressing breast cancer screening in asymptomatic, average-risk women.

Here are the ACP's four principal recommendations:

  • For women aged 40-49 years, clinicians should review pros and cons of mammography, taking into account a woman's preferences. The ACP cautioned that for most women in this age group, harms from screening outweigh the benefits.

  • For women aged 50-74 years, clinicians should offer biennial mammograms.

  • Women aged 75 years or older or those with a life expectancy of 10 years or less should discontinue screening.

  • Regardless of age, screening clinical breast examinations are not recommended.

The ACP noted that, overall, the magnitude of reduction of breast cancer mortality associated with mammography is small, a point they felt that most guidelines did not emphasize. In addition, looking at all age groups, mammography was not found to reduce all-cause mortality.

While mammography was consistently found to reduce breast cancer mortality in women aged 50-69 years, most reviewed studies failed to demonstrate a similar reduction among younger women.

All reviewed evidence found that women aged 39-49 years received the least benefit from screening with respect to deaths prevented. In addition, screening in this age group was not found to reduce the incidence of advanced breast cancer. In these younger women, the harms, including overdiagnosis, overtreatment, false-positive results, and unnecessary diagnostic testing (including biopsies) outweighed the benefits of screening.

Regarding the frequency of mammography, the benefits of annual screening were not clearly superior to screening every 2 or 3 years. However, annual screening was associated with more harms.

The topic of breast cancer screening remains controversial. As editorialists point out,[2] while the ACP guidance pertains to average-risk women, many low-risk women perceive that they are very high-risk. I agree with the editorialists that in the setting of a brief well-woman visit, our challenge is to help women understand and implement evidence-based breast cancer screening.

Thank you for the honor of your time. I am Andrew Kaunitz.

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