ACS tries to find mammography middle ground, recommends screening from age 45

The American Cancer Society (ACS) has issued new recommendations for screening mammography, urging women of average risk to get annual mammograms starting at age 45, rather than age 40.

The change is the latest in the ongoing debate over the optimal breast cancer screening strategy, and could be seen either as further muddying the waters of an already complicated decision or as an attempt to bridge the gap between other groups’ recommendations.

American College of Radiology (ACR) and Society of Breast Imaging (SBI) recommendations, among others, recommend annual mammography starting at age 40, which was the strategy previously endorsed by ACS. Meanwhile, the U.S. Preventive Services Task Force (USPSTF) continued to rankle supporters of aggressive screening intervals earlier this year when it reaffirmed its recommendation of routine biennial screening for women ages 50 to 74 only.

“After careful examination of the burden of disease among women aged 40 to 54 years, the guideline development group (GDG) concluded that the lesser, but not insignificant, burden of disease for women aged 40 to 44 years and the higher cumulative risk of adverse outcomes no longer warranted a direct recommendation to begin screening at age 40 years,” wrote Kevin C. Oeffinger, MD, of Memorial Sloan Kettering Cancer Center in New York City, and colleagues, who authored the new guidelines.

ACS’ updated recommendations were published this week in JAMA.

Aside from shifting the start of routine mammography to age 45, other ACS recommendations for women of average risk included:

• Women 45 to 54 years of age should be screened annually.
• Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually.
• Women should have the opportunity to begin annual screening between the ages of 40 and 44 years.
• Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer.
• Clinical breast examination is not recommended for breast cancer screening among average-risk women at any age.

With regard to dropping recommendations for clinical breast exams, the ACS guidelines cited a lack of clear evidence that the physical exams significantly contributed to breast cancer detection for average-risk women of any age.

In an accompanying editorial, Nancy L. Keating, MD, MPH, of Harvard Medical School, and Lydia E. Pace, MD, MPH, of Brigham and Women’s Hospital in Boston, highlighted the fact that newer recommendations are attempting to balance the individualized values and preferences of patients.

“In some ways, the messages from ACS and the [USPSTF], 2 major guidelines, are now more consistent. Both guidelines agree that for average-risk women younger than 45 years, the harms of mammography screening likely outweigh the benefits,” they wrote.

The most challenging decisions will be made by women ages 45 to 54, according to Keating and Pace. ACS and USPSTF recommendations differ the most in this group, both on the decision of whether to start screening at all before age 50 and on annual versus biennial screening for women age 50 to 54.

A joint statement from the ACR and SBI lauded the ACS for acknowledging the benefits of mammography for women in their 40s, though both organizations will continue to recommend regular mammography starting at age 40. The statement also pushed back on ACS’ recommendation that older women consider transitioning to biennial screening, with the ACR and SBI endorsing continued annual screening.