Screening for Breast Cancer

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There is controversy in when to initiate and how often to screen for breast cancer with mammography. Below is a summary of various aspects of screening for breast cancer. A more detailed report can be found at the US Preventative Services Task Force (USPSTF) website:

http://www.ahrq.gov/clinic/3rduspstf/breastcancer/

When to start screening with mammography?

All guidelines released by major North American organizations recommend screening mammography for women>50 years old. The majority of controversy lies whether to screen women between 40-49.

According to the US Preventative Services Task Force (USPSTF) there are 6 randomized trials on mammography of fair quality that included women ages 40-49. Only one trial showed a significant mortality benefit. In a meta-analysis, the summary relative risk of breast cancer mortality was 0.85 (95 percent CI, 0.73-0.99) among screened women after 13 years of observation. The number needed to screen to save one life was 1792. None of the trials specifically address when to initiate screening, and some question whether this mortality benefit could be captured by initiating screening at age 50.

The USPSTF, American Medical Association (AMA), the American College of Obstetricians and Gynecologists (ACOG), the American College of Radiology (ACR), and the American Cancer Society (ACS), all support screening with mammography beginning at age 40. The Canadian Task Force on Preventive Health Care (CTFPHC), the American Academy of Family Physicians (AAFP), and the American College of Preventive Medicine (ACPM) recommend initiating mammography for average-risk women at age 50. AAFP and ACPM recommend that mammography in high-risk women begin at age 40, and AAFP recommends that all women aged 40-49 be counseled about the risks and benefits of mammography before making decisions about screening.

In that competing causes of mortality decrease the effectiveness of any screening program, at Madison Clinic the decision of when to start screening for breast cancer is complex. The majority of US organizations recommend initiating screening for breast cancer at the age of 40 while others recommend initiating screening at the age of 50. At Madison Clinic we accept either approach. It seems prudent to involve the patient in this complex decision.

How often to screen for breast cancer?

According, the USPSTF “for women aged 50 and older, there is little evidence to suggest that annual mammography is more effective than mammography done every other year. For women aged 40-49, available trials also have not reported a clear advantage of annual mammography over biennial mammography.”

However, annual mammography is recommended by AMA, ACR, and ACS. Mammography every 1-2 years is recommended by USPSTF, AAFP, ACPM, and the CTFPHC. ACOG recommends annual mammography every 1-2 years for women aged 40-49 and annually for women aged 50 and older.

Should a routine clinical breast exams or routine self-breast exams be performed?

The USPSTF considers there to be insufficient evidence to recommend for or against either intervention.

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