New Screening Mammogram Guidelines: Another Thing to Think About
Wondering what the impact on doctors of the recently announced "new" guidelines on screening mammography might be, I took a look on the websites of the most significant medical organizations representing doctors who would be the most likely to be involved in recommending a screening mammogram for an individual. (All italics are mine; organization names are links)
The American Academy of Family Physicians posts on its website guidelines dating to 2004 and adhering to the American Cancer Society's guidelines, which remain in effect:
Women at average risk for breast cancer should begin regular mammography at age 40 and should be informed of the benefits, limitations, and potential harms associated with screening. A "baseline" mammogram at age 35 is no longer recommended. The importance of adhering to a schedule of annual mammograms should be stressed.
The American College of Physicians, in its Journal of Internal Medicine, still posts guidelines from April 2007, quoted below:
Recommendation 3: For women 40 to 49 years of age, clinicians should base screening mammography decisions on benefits and harms of screening, as well as on a woman's preferences and breast cancer risk profile.
Because the evidence shows variation in risk for breast cancer and benefits and harms of screening mammography based on an individual woman's risk profile, a personalized screening strategy based on a discussion of the benefits and potential harms of screening and an understanding of a woman's preferences will help identify those who will most benefit from screening mammography. For many women, the potential reduction in breast cancer mortality rate associated with screening mammography will outweigh other considerations. For women who do not wish to discuss the screening decision, screening mammography every 1 to 2 years in women 40 to 49 years of age is reasonable.
Important factors in the decision to undergo screening mammography are women's preferences for screening and the associated outcomes. Concerns about risks for breast cancer or its effect on quality of life will vary greatly among women. Some women may also be particularly concerned about the potential harms of screening mammography, such as false-positive mammograms and the resulting diagnostic work-up. When feasible, clinicians should explore women's concerns about breast cancer and screening mammography to help guide decision making about mammography.
The relative balance of benefits and harms depends on women's concerns and preferences and on their risk for breast cancer. Clinicians should help women to judge the balance of benefits and harms from screening mammography. Women who are at greater-than-average absolute risk for breast cancer and who are concerned that breast cancer would have a severely adverse effect on quality of life may derive a greater-than-average benefit from screening mammography. Women who are at substantially lower-than-average risk for breast cancer or who are concerned about potential risks of mammography may derive a less-than-average benefit from screening mammography.
If a woman decides to forgo annual mammography, clinicians should readdress the decision to have screening every 1 to 2 years.
Recommendation 4: We recommend further research on the net benefits and harms of breast cancer screening modalities for women 40 to 49 years of age.
Methodological issues associated with existing breast cancer screening trials, such as compliance with screening, lack of statistical power, and inadequate information about inclusion or exclusion criteria and study population, heighten the need for high-quality trials to confirm the effectiveness of screening mammography in women in this age group. Furthermore, harms of screening in this age group, such as pain, radiation exposure, and adverse outcomes related to false-positive results, should also be studied.
The National Comprehensive Cancer Network (NCCN), in its clinical practice in oncology guidelines, says physicians should use screening mammograms when appropriate. They do not recommend using them for all patients in a particular population group. The following is excerpted from the NCCN online journal for November 2009.
...mortality from breast cancer has decreased slightly, attributed partly to mammography screening. Breast screening is performed in women without any signs or symptoms of breast cancer so that disease can be detected as early as possible. The components of a breast screening evaluation depend on patient age and other factors, such as medical and family history, and can include breast awareness (i.e., patient familiarity with her breasts), physical examination, risk assessment, screening mammography, and, in selected cases, screening MRI. These practice guidelines were designed to facilitate clinical decision-making. [Non-clinical] General public and health care providers must be aware that mammography or any other imaging modality is not a stand-alone procedure. Neither the current technology of mammography or other imaging tests nor the subsequent interpretation of these tests is foolproof. Patient concerns and physical findings must be considered along with the results of imaging and histologic assessment.
The American Congress of Obstetricians and Gynecologists (ACOG) has guidelines for patients on its website that recommend screening every one or two years for women 40-49 unless the woman has an increased risk of breast cancer. Its guidelines suggest that the problem of dense breasts that obscure mammogram results in young women is lessened after age 40.
The American College of Radiology (ACR), the organization of physicians who perform/read mammograms, adheres to the recommendation of annual screening for all women 40 and older. On November 16 ACR posted on its website a response to the Task Force recommendation saying the only reason for them was to cut costs of medical insurance and treatment and unfairly ration medical care. My take on this is admittedly cynical: Since the members of this medical organization have the most to lose financially if women cut back on the number and/or frequency of mammograms they undergo, one can only wonder what motivates their strident response, the headline of which was: "USPSTF Mammography Recommendations Will Result in Countless Unnecessary Breast Cancer Deaths Each Year".
If you are interested in the full text of any of these guidelines, you need only google their name on the Internet or follow the links provided above..
Posted December 17, 2009.
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