Most Breast Cancer Screening Centers Not Following Guidelines

Roxanne Nelson, RN, BSN

March 18, 2021

Most breast cancer screening centers in the United States are not following national guidelines, say researchers reporting a new analysis.

They assessed 606 centers and report that, among the centers that recommended a starting age for screening mammography, nearly 90% advised women to begin screening at age 40 years and to continue annually.

This contrasts with the current recommendations from the US Preventive Services Task Force (USPSTF) on mammography screening, which stipulate starting at age 50 years and continuing every 2 years.

The new analysis was published online March 15 in JAMA Internal Medicine.

This may be doing "more harm than good," warn the authors of an accompanying editorial.

"The recommendation for annual mammography in women younger than 50 years is, at best, confusing for patients and is likely to conflict with advice from their primary care physicians, which can create tension," write Anand R. Habib, MD, MPhil, Deborah Grady, MD, and Rita F. Redberg, MD, all from the University of California, San Francisco.

"This recommendation can also produce unnecessary testing, invasive procedures, overdiagnosis, and anxiety among women who receive screening," they write.

"Breast cancer centers with clear financial benefits from increased mammography rates may wish to reconsider offering recommendations that create greater referral volume but conflict with unbiased evidence-based USPSTF guidelines and have the potential to increase harms among women," the editorialists add.

The age at which to start mammography screening has long been a contentious issue, with some experts and medical societies arguing that it should begin at 40.

The American College of Radiology, the Society of Breast Imaging, and the American Society of Breast Surgeons recommend that women start annual mammography screening at age 40.

The American Cancer Society's guidelines recommend an initial screening mammogram between ages 45 and 55 and then continuing screening every 1 to 2 years.

One expert who argues for starting at 40 years is Laurie Margolies, MD, chief of breast imaging, Mount Sinai Health System, and professor of radiology, Icahn School of Medicine at Mount Sinai, New York City.

In a statement, she noted that 17% of all breast cancers are diagnosed in women in their 40s and that the majority of these women are not considered to be at high risk of developing the disease.

"Our own Mount Sinai research has shown that women with screen-detected breast cancers are less likely to need a mastectomy and are less likely to require chemotherapy or axillary node dissection," Margolies said.

"Additionally, women who get regular breast cancer screening have a 47% lower risk of breast cancer death within 20 years of diagnosis than those not regularly screened. Skipping a mammogram can have lethal consequences," she said.

Details of the Analysis

The analysis of recommendations by breast cancer centers regarding screening mammography was carried out by Jennifer L. Marti, MD, from Weill Cornell Medicine, New York City, and colleagues.

They examined 606 centers and found that 487 (80.4%) offered screening recommendations on their public websites.

Of 431 centers that recommended a starting age, 376 centers (87.2%) advised women to begin screening at age 40 years; 35 centers (8.1%) recommended beginning at age 45 years; and the remaining 20 centers (4.6%) recommended that screening begin at age 50 years.

A total of 429 centers recommended both a starting age and a screening interval. Of this group, 347 centers (80.9%) advised that annual screening begin at age 40 years. Only 16 centers (3.3%) recommended biennial mammography (as per the USPSTSF guidelines). Almost three quarters (72.7%, n = 354) recommended annual screening; 59 centers (12.1%) recommended annual or biennial screening; and 58 centers (11.9%) recommended a discussion with a physician.

The authors note that there were differences between centers that were and those that were not designated National Cancer Institute centers, but these differences did not reach statistical significance.

Marti and co-authors, Habib and co-authors, and Margolies have disclosed no relevant financial relationships.

JAMA Intern Med. Published online March 15, 2021. Full text, Editorial

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