not use supplemental MRI or ultrasound.<\/li>\n<\/ul>\nScreening guidance varies across organizations<\/h2>\n Crandall said the new guidelines are meant to reconcile conflicting recommendations across medical organizations.<\/p>\n
The U.S. Preventive Services Task Force recommends biennial screening for women aged 40 to 74 years. The recommendation does not apply to women with a personal history of breast cancer, those who had a lesion on previous biopsies, and those who have a very high risk for breast cancer because of a history of high-dose radiation therapy to their chest at a young age or certain genetic markers. The task force said there was not enough evidence to make a recommendation for or against screening in women aged 75 years or older.<\/p>\n
Meanwhile, the American College of Radiology (ACR) recommends annual breast cancer screening starting at age 40 years. It also recommends that all women receive a breast cancer risk assessment by age 25 years to determine if screening is needed earlier. Black and Ashkenazi Jewish women were specifically highlighted by ACR as those who may benefit from earlier screening, as research shows they are at much higher risk for breast cancer mortality compared with other populations.<\/p>\n
The American Cancer Society (ACS) recommends that women have the option to begin screening at age 40 years, but by age 45 years, the society recommends annual screening. Also, beginning at age 55 years, women should have the option to switch to biennial screening or continue yearly mammograms.<\/p>\n
Neither the ACS nor ACR recommendations were included in ACP\u2019s assessment during the development of its guidelines because they \u201cdid not meet our inclusion criteria,\u201d Crandall told Healio.<\/p>\n
\u201cAny guideline that is older than 5 years is considered expired since the data utilized is quite old. The ACS has not updated its breast cancer screening guideline since 2015,\u201d she said. \u201cACP\u2019s guidance statements focus on recently updated or published guidelines (last 5 years) because ACP aims to assess the most up-to-date evidence and clinical thinking to make guidance as useful as possible to clinicians and patients.\u201d<\/p>\n
ACR\u2019s guidance, she noted, does not fit the definition of a clinical guideline because it was not based on a systematic review.<\/p>\n
\u201cThe accepted definition of a guideline by National Academy of Medicine (NAM) and Guidelines International Network (GIN) clearly states that a document to be considered a guideline should have been informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options,\u201d she said. \u201cIn addition, some organizations do not follow the currently acceptable standards to develop high-quality guidelines that have been recommended by NAM and GIN. Variation in methods, including following different processes for important and critical issues such as disclosure of interests and how conflicts of interest are managed … need to be kept in mind.\u201d<\/p>\n
Clashing views<\/h2>\n Crandall said the ACP guidelines reflect the potential risks of more frequent mammography, including the possibility of more false positives, biopsies, radiation exposure, patient burden and costs. <\/p>\n
\u201cWe\u2019re trying to get the right balance,\u201d she said during the plenary. \u201cWe have to feel comfortable with our best evidence out there.\u201d<\/p>\n
One notable difference between ACP and ACS guidelines is that the latter \u201cdidn\u2019t specifically review whether breast cancer mortality is different with annual vs. biennial,\u201d Crandall said. \u201cBut we really need more data regarding breast frequency.\u201d<\/p>\n
However, Robert A. Smith, PhD,<\/b> senior vice president of early cancer detection science at ACS, said that ACP is \u201ckind of behind the evolution of breast cancer screening\u201d in some aspects.<\/p>\n
\u201cWe understand that breast cancer screening is beneficial in women ages 40 to 49 years, so I think it\u2019s not really necessary to position this for shared decision-making,\u201d he told Healio. \u201cIn fact, having done that, they cast doubt on the value of breast cancer screening.\u201d<\/p>\n
Smith said that clinicians understand shared decision-making \u201cas being something that you do to discuss prostate cancer screening, for example \u2014 it\u2019s judged to be not clear that the possibility of harms against the possibility of benefits is a clear choice, and so it\u2019s referred to as a highly preferent decision.\u201d<\/p>\n
\u201cInformed decision-making simply means patients need to know why this test is beneficial and what to expect from it, and they certainly can choose not to undergo the test if they prefer,\u201d he said. \u201cBut most women already, and for decades, have embraced mammography screening beginning at the age of 40 years.\u201d<\/p>\n
Smith additionally pointed out that asymptomatic, average-risk women with breast density of BI-RADS categories C or D \u201cneed supplemental imaging, and that can be done with ultrasound or MRI.\u201d<\/p>\n
\u201cTo not recommend that is essentially saying, \u2018You should accept an incomplete examination,\u2019\u201d Smith said. \u201cIf you have areas of density in your breast where a radiologist is not able to say with confidence that there\u2019s a tumor there or not, these other technologies \u2014 mainly MRI because its functional imaging, not anatomical imaging \u2014 penetrate that density.\u201d<\/p>\n
Smith said that ACS\u2019 guidance is \u201cquite useful, but doctors are very sensitive to what\u2019s covered under the Affordable Care Act, and right now, the Affordable Care Act is under law that coverage has to exist according to an A or B rating from the [USPSTF].\u201d<\/p>\n
\u201cI share everyone\u2019s frustration when guidelines are different,\u201d he said. \u201cGuideline-developing organizations commonly do not collaborate.\u201d<\/p>\n
Ultimately, ACP\u2019s guidance \u201cis very conservative,\u201d including when it comes to women aged 75 years and older, Smith said. <\/p>\n
A recent study supports continued mammography in older women. The retrospective analysis found that women who were diagnosed with breast cancer at age 80 years or older had a 55% lower risk for recurrence and more than 70% lower risk for death if they were screened within 2 years of diagnosis.<\/p>\n
Crandall stressed that the new ACP guidelines do not recommend discontinuing screening after 74 years.<\/p>\n
\u201cWhat we are saying, though, is to discuss discontinuation based on shared-decision making,\u201d she said. \u201cThus far, we have few data from randomized trials among people aged beyond 74 years. But those data have not yet shown a decrease in mortality from breast cancer if you continue screening beyond age 74. There is evidence of harm from continuing screening \u2014 more tests, overdiagnosis and over treatment of something that would not necessarily cause symptoms or affect a person\u2019s lifespan. That\u2019s based on modeling studies. We really do need more data in this group.\u201d<\/p>\n
For more information:<\/h2>\n Carolyn<\/b> <\/b>J.<\/b> <\/b>Crandall,<\/b> <\/b>MD, MS, MACP<\/b>, <\/b>and Robert<\/b> A.<\/b> Smith, PhD,<\/b> <\/b>can be reached at primarycare@healio.com.<\/p>\n\n
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