Feature | Breast Imaging | September 07, 2018 | By JoAnn Pushkin

Confused About Mammogram Screening Guidelines?

Given the disparity in mammography guidelines, it can be a challenge to explain why and what the most appropriate screening protocol is for a patient

Mammogram Guidelines for Dense breast tissue

Dense breast tissue categories include fatty, scattered fibroglandular density, heterogeneously dense and extremely dense.

JoAnn Pushkin

JoAnn Pushkin

comparison for breast screening guidelines and mammography guidelines

This chart shows a comparison for breast screening guidelines.

Breast cancer screening and mammography screening guidelines

Breast cancer screening guidelines, a comparison by mammography interval.

If you are confused about the conflicting advice surrounding mammography screening guidelines, welcome to the club. When should mammography screening begin? How often is screening necessary? When should screening end? The varying national breast screening guidelines may have both patients and health providers uncertain as to appropriate recommendations. As the screening guideline discussion is one which has found traction in the news and on social media, it may be a challenge to address a patient’s questions about why her own screening protocol differs from what she may be hearing.

In January 2016, and with much media attention, the U.S. Preventive Service Task Force (USPSTF) issued its final breast cancer screening recommendations. These recommendations differ from those of several national health organizations and have generated confusion and conflicting messaging on the topic within the public arena. Since the USPSTF final guidelines were issued — which recommend screening begin at age 50 and at two-year intervals — the American College of Radiology/Society of Breast Imaging (ACR/SBI), the American Cancer Society (ACS) and the American Congress of Obstetricians and Gynecologists (ACOG) have also updated their own recommendations.

To assist with an analysis of the guideline recommendations, DenseBreast-info.org developed the Breast Cancer Screening Guideline Comparison. Note that the ACS now recommends screening starting at age 45 with an option to start at 40, while ACOG recommends offering screening starting at age 40 but not later than 50. The ACR/SBI, American Medical Association (AMA) and National Comprehensive Cancer Network (NCCN) continue to recommend screening beginning at age 40 and continuing at an annual interval. The ACS suggests mammography interval annually for ages 45-54, and every one to two years at age 55 and older, while ACOG suggests every one to two years without age qualifiers.

The age to stop mammography also differs among guidelines and varies from a specific age cutoff (USPSTF suggests 74 years of age, ACOG suggests age 75 and then shared decision making), to stopping when life expectancy is less than 10 years (ACS), to no specified age limit with recommendation tailored to the individual patient’s health status (ACR/SBI). The AMA and NCCN do not state an age to stop mammography screening.

In light of the growing availability and utilization of 3-D mammography (also known as tomosynthesis), several guidelines also include their view on the technology’s benefits, and these also differ. The ACR/SBI, ACS and NCCN find it an “improvement” over 2-D mammography in terms of detection and recall. Because the USPSTF only considers data from randomized trials with mortality as an endpoint, and there are no such trials of any breast imaging other than mammography, USPSTF’s position is that there is still “insufficient evidence to support routine use.” The ACOG and the AMA do not state positions on 3-D.

Given the disparity in the guidelines, it can be a challenge to explain why and what the most appropriate screening protocol is for a patient. DenseBreast-info.org believes that patients should start their screening mammograms before age 45 for the following reasons:

• The entire reason we screen for breast cancer is to find it early, when most treatable and survivable.

• Breast cancer is the No. 1 cause of death in women aged 35 to 54 years.

• Mammography has been proven to reduce deaths due to breast cancer in women screened beginning at age 40.

• 25 percent of all years of life lost to breast cancer occur in women diagnosed before the age of 45.

• Women at “high risk” for breast cancer due to known or suspected disease-causing mutation (such as BRCA1 or BRCA2) should begin screening at least by age 30, to include magnetic resonance imaging (MRI).

 

The American College of Radiology also recommends annual MRI in addition to mammography in women determined to be at “higher than average risk,” which includes all women diagnosed with breast cancer at/by age 50 and women diagnosed at any age with a personal history of breast cancer and dense breasts.1

 

What about false positives?

• About 10 percent of women having a screening mammogram will be called back for extra testing or views. This is normal. Among women called back, 95 percent do not have cancer. If a needle biopsy is necessary, even that is a simple test.

• The newer technique of 3-D mammography (tomosynthesis) is better able to show cancer and results in fewer callbacks for extra testing.

 

What about screening in dense breasts?

• Younger women are more likely to have dense breast tissue, which can hide cancer on mammography.

• In women who have breasts categorized as “dense” (heterogeneously dense or extremely dense), adding screening ultrasound (if the woman is not a high risk) after a mammogram (2-D or 3-D) can help find more breast cancers. Because ultrasound detects more areas that need follow-up, there is more to check. Ultrasound also increases the chance of needing a needle biopsy to determine if something detected is cancerous or not.

 

Reference

1. Monticciolo DL et al. J Am Coll Radiol. 2018 Mar;15(3 Pt A):408-414.doi: 10.1016/j. jacr.2017.11.034. Epub 2018 Jan 19.

 

JoAnn Pushkin is executive director of DenseBreast-info, Inc. For more information on breast screening, risk factors and dense breasts, visit DenseBreast-info.org.

© DenseBreast-info Inc. and JoAnn Pushkin

Related Content

Building on prior success combining Cyclin-Dependent Kinase (CDK) inhibitors with hormone therapy to treat breast cancer, researchers are now exploring the potential integration of CDK inhibitors with radiotherapy

Schematic overview of cell cycle regulation, with an emphasis on radiotherapy-induced pathways and CDK/cyclin regulation. In M phase and in G2 resting phase, cancer cells are respectively very sensitive and moderately sensitive to radiation injury, whereas in G1 phase and in S phase, cancer cells are moderately resistant to radiation injury. Irradiation induces G1 and G2 cell cycle checkpoint activation and DNA repair. Most cancer cells are defective in G1 checkpoint, commonly due to the mutations/alterations of the key regulators of the G1 checkpoint, but contain a functional G2 checkpoint. Figure courtesy of The International Journal of Molecular Sciences

News | Radiation Therapy | August 18, 2021
August 18, 2021 — Building on prior success combining Cyclin-Dependent Kinase (CDK) inhibitors with hormone therapy t
DenseBreast-info.org (DB-I) announced that the European Society of Radiology (ESR) now links to DB-I website and educational materials as a resource for members about the screening and risk implications of dense breast tissue.
News | Breast Density | August 13, 2021
August 13, 2021 — 
artificial intelligence-based computer-aided detection (AI-CAD) can be a practical addition for lowering false-positive findings when performing post-breast conserving therapy (BCT) surveillance mammography

AI-CAD marked axillary lymph node and region in right upper outer quadrant (arrows and thin line outlining both sites) and assigned an abnormality score of 28%.

News | Breast Imaging | August 11, 2021
Receiver operator characteristics curve for the optimal response classifiers, optimized for maximum F1-Score. The AUCs for each classifier are reported in the legend. Image courtesy of Gregory J. Czarnota

Receiver operator characteristics curve for the optimal response classifiers, optimized for maximum F1-Score. The AUCs for each classifier are reported in the legend. Image courtesy of Gregory J. Czarnota - [email protected]

News | MRI Breast | August 06, 2021
August 6, 2021 — Oncotarget published "...
The Council on Radionuclides and Radiopharmaceuticals, Inc. (CORAR), along with physicians and patient organizations, supports the introduction of H.R. 4479, the “Facilitating Innovative Nuclear Diagnostics (FIND) Act of 2021” by Congressmen Scott Peters (D-CA), Bobby Rush (D-IL), Neal Dunn (R-FL) and Greg Murphy (R-NC).

Getty Images

News | Nuclear Imaging | August 04, 2021
August 4, 2021 — The Council on Radionuclides and Radiopharmaceuticals, Inc.
Right mediolateral oblique (MLO) mammograms for different women with the same breast thickness but varying breast density.

Right mediolateral oblique (MLO) mammograms for different women with the same breast thickness but varying breast density.

News | Breast Imaging | July 30, 2021
July 30, 2021 — Volpara Health, a global health technology software leader providing an integrated breast care platfo
Volpara Health, a global health technology software leader providing an integrated breast care platform for the delivery of personalized breast care, has signed an agreement with Invitae Corporation, a leader in medical genetics, to bring Invitae's genetic testing services to Volpara's customers in the United States. 
News | Breast Imaging | July 29, 2021
July 29, 2021 — Volpara Health, a global health technology software leader providing an...
Registration is now open for the Radiological Society of North America (RSNA) 107th Scientific Assembly and Annual Meeting, the world’s largest annual radiology forum, to be held at McCormick Place Chicago, Nov. 28 – Dec. 2, 2021

Getty Images

News | RSNA | July 21, 2021
July 21, 2021 — Registration is now open for the Radiological Society of North America (...