Minnesota Academy of Family Physicians

Still Talking About Changes in Breast Cancer Screening Recommendations? You Should Be...With Your Personal Physician

- Education from the Minnesota Academy of Family Physicians -

August 2, 2010

If you’re a woman unsure about when to get your first mammogram, you’re not alone. Patients across the state have been getting mixed messages from clinic groups, the media, and other medical organizations about breast screening guidelines after changes were made by the U.S. Preventive Services Task Force (USPSTF). The Task Force is an independent panel of experts in primary care and prevention convened by the Agency for Healthcare Research and Quality. One common concern is based on a misperception that the USPSTF recommended that women under the age of 50 no longer need to get mammograms unless they’re in a high-risk group. The actual intent of the recommendations, which were based on recent data about mammography’s risks and benefits for women at varying ages, was to get women and their physicians to talk about the value of routine annual mammograms.

“I see it as an opportunity for personalized cancer screening. As family physicians, we are well-qualified to translate the recommendations into meaningful conversations with our patients,” said Patricia Fontaine, M.D., MS, an associate professor and researcher with the University of Minnesota Department of Family Medicine and Community Health. “Prior to the USPSTF’s recommendations, I advised my patients to get a baseline mammogram at age 35 to 40, based on their risk for breast cancer. We’ll still have those discussions now. But if a patient says, ‘What is the downside if I wait a year or two?’ then I say, ‘Let’s look carefully at your risk, and maybe it’s a possibility. ”

The new guidelines by the USPSTF recommend screening mammography every two years for women aged 50 to 74 years, instead of every year as previously stated. The USPSTF also concludes that current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Finally, the new guidelines say that the decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.

Routine screening can have negative aspects for women at any age. Potential harms cited by the USPSTF include unnecessary imaging tests and biopsies in women without cancer, exposure to radiation from the mammogram, over diagnosis and over treatment of slow-growing cancers, as well as the inconvenience and the psychological harms due to false-positive screening results. These false-alarms are more common in women aged 40 to 49 years.

The American Academy of Family Physicians (AAFP) updated its cancer screening recommendations to coincide with those by the USPSTF based on the evidence report the task force developed. The AAFP says in determining what is best for each patient, a person’s medical history, as well as the scientific evidence regarding the effectiveness of each screening test should be considered. Family physicians supporting the changes believe the new recommendations give women the option of figuring out what is best for them and encouraging individualized discussion with a trusted doctor.

A useful tool for determining a woman’s risk is available at http://www.cancer.gov/bcrisktool/Default.aspx. This tool (not applicable for a woman with known BRCA-positive hereditary breast cancer) is for use by health professionals and takes only seconds to do. It provides detailed risk analysis for lifetime and for the next 5 years, for example it would conclude, “Based on the information provided, the woman's estimated risk for developing invasive breast cancer over the next 5 years is 1.9% compared to a risk of 1.7% for a woman of the same age and race/ethnicity from the general U.S. population. This calculation also means that the woman's risk of NOT getting breast cancer over the next 5 years is 98.1%.”

“Breast cancer is the second-leading cause of cancer death among women in the United States so this is obviously an important issue,” said Dr. Fontaine. “Family physicians need to understand the controversy about mammograms and be systematic in assessing risk in order to address women’s concerns. Screening is a valuable tool in detecting and successfully treating breast cancer, so it should be top priority for a woman and her physician.”