FROM ANNALS OF INTERNAL MEDICINE

Women aged 50-74 years should undergo biennial screening mammography, and the decision to screen before age 50 should be individualized, according to a final recommendation from the U.S. Preventive Services Task Force.

The recommendation statement, published Jan. 11 in Annals of Internal Medicine, is based on a comprehensive review of data since 2009, when the USPSTF last released breast cancer screening recommendations, and follows a public comment period in early 2015.

“The task force continues to find that the benefit of mammography increases with age, and recommends biennial screening in women ages 50 to 74. Mammography can also be effective for women in their 40s, but the benefits are less and the harms potentially greater. The decision by women to start screening in their 40s should be an individual one, made in partnership with a doctor,” according to a statement from the USPSTF.

The new recommendations will not affect private insurance coverage of mammography without cost sharing as outlined in the Affordable Care Act. As part of a spending bill enacted in December 2015, Congress passed a provision placing a 2-year moratorium on the use of any new USPSTF recommendations related to breast cancer screening to determine coverage, effectively preserving mammography coverage without cost sharing for women aged 40 years and older.

Recommendations by age

The latest USPSTF recommendations by age state that women aged 40-49 years should base their screening decision on personal values, preferences, and health history; women with a family history of breast cancer may benefit more than average-risk women by beginning screening before age 50. This is a C recommendation, indicating “moderate certainty that net benefit is small.”

The recommendation for biennial screening of those aged 50-74 is a B recommendation indicating “high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial,” Dr. Albert L. Siu, task force chair, reported on behalf of the USPSTF (Ann Intern Med. 2016;164:279-96. doi: 10.7326/M15-2886).

The task force found inadequate evidence to recommend for or against screening those aged 75 and older.

Final evidence documents, including a systematic review of data on the harms associated with breast cancer screening and a modeling study of the benefits and harms associated with different screening strategies, are published along with the recommendation statement.

The USPSTF did not make a recommendations about the use of digital breast tomosynthesis as a primary screening method for breast cancer, noting that the current evidence is insufficient. Evidence also was insufficient to make a recommendation on the benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, digital breast tomosynthesis, or other methods in women with dense breasts who had a negative screening mammogram.

Dousing the ‘firestorm’

In an editorial penned by Annals of Internal Medicine Editor-in-Chief and Senior Vice President of the American College of Physicians Christine Laine and her colleagues, they urged a dousing of the “firestorm around breast cancer screening.”

That firestorm was ignited with the 2009 USPSTF breast cancer screening recommendation and was rekindled when the current recommendation was presented in draft form in 2015.

However, “the USPSTF did a difficult job well” and based its recommendations on an important understanding of the updated evidence, as well as potential harms and tradeoffs of different screening strategies, the authors wrote.

“When the USPSTF posted its draft recommendations for comment, it noted, ‘Women deserve to be aware of what the science says so they can make the best choice for themselves, together with their doctor.’ We could not agree more. Let’s douse the flames and clear the smoke so that we can clearly see what the evidence shows and where we need to focus efforts to fill gaps in our knowledge so that women, along with their health care providers, can make the best decision to reduce their risk for breast cancer–related morbidity and mortality,” they wrote (Ann Intern Med. 2016 Jan 11. doi:10.7326/M15-2978).

ACOG supports screening at 40

The American College of Obstetricians and Gynecologists is standing by its recommendation of annual mammograms beginning at age 40 and continues to support use of clinical breast examinations. In a Jan. 11 statement, Dr. Mark S. DeFrancesco, ACOG president, said that “evidence and experience have shown that early detection can lead to improved outcomes in women diagnosed with breast cancer.”

The organization similarly stood by its recommendation in October 2015, when the American Cancer Society released recommendations for annual screening mammography for asymptomatic women at average risk for breast cancer beginning at age 45 years, with a transition to biennial screening mammography beginning at age 55 (JAMA. 2015;314[15]:1599-1614. doi: 10.1001/jama.2015.12783).

ACOG also supports the omnibus legislation passed by Congress in December that provides 2 years of no-copay coverage of breast cancer screening after age 40 via a moratorium on new breast cancer screening recommendations to allow time for additional research, an ACOG spokesperson said in an interview.

“ACOG strongly supports shared decision-making between doctor and patient, and in the case of screening for breast cancer, it is essential,” Dr. DeFrancesco said. “Given the differences among current organizational recommendations on breast cancer screening, we recognize that there may be confusion among women about when they should begin screening for breast cancer. ACOG encourages women to discuss this with their doctor, including concerns such as family history of cancer, risk factors such as overweight, and their own personal experiences with breast cancer. Moreover, it is essential that physicians counsel women about the potential consequences of mammography, including false positives.”

ACOG will convene a consensus conference later in January “with the intent to develop a consistent set of uniform guidelines for breast cancer screening that can be implemented nationwide” in an effort to “avoid the confusion that currently exists among the women we treat,” according to the statement.

The issue of divergence – and convergence – among various guidelines was the topic of another editorial published in conjunction with the USPSTF recommendations. In that article, task force chair Dr. Siu and his colleagues acknowledged that disagreements exist but stressed that “it would be a disservice to women and their clinicians if these disagreements obscured a strong emerging convergence among groups who have recently issued evidence-based guidelines” (Ann Intern Med. 2016 Jan 11. doi:10.7326/M15-3065).

The operations of the USPSTF are supported by the Agency for Healthcare Research and Quality. One of the members of the USPSTF reported receiving past grants and contracts from the National Cancer Institute and the Centers for Disease Control and Prevention.

sworcester@frontlinemedcom.com

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