In the News
The U.S. Preventive Services Task Force (USPSTF) released updated breast cancer screening recommendations in the February 16 issue of Annals of Internal Medicine, essentially reasserting its controversial recommendations from 2009. The group still recommends that asymptomatic women from 40 to 49 years of age at average risk not automatically undergo screening but weigh the possible benefits and harms and decide in consultation with their provider whether to begin biennial screening. The task force gave that recommendation a rating of C, according to its criteria, meaning that “[t]here is at least moderate certainty that the net benefit is small.” It also recommends that women 50 to 74 years of age receive biennial mammographic screening (a grade B recommendation: “[t]here is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial”).
For women 75 years old and older the USPSTF provides no recommendation, citing insufficient evidence. The USPSTF notes, too, the possible harms—overdiagnosis and unnecessary treatment—of mammographic screening in women in their 40s. Although the task force acknowledges that the benefits outweigh the possible harms in that age group, it did not find that advantage to be significant enough to warrant biennial screening.
The USPSTF's recommendations differ from those of the American Cancer Society (ACS), which call for women ages 40 to 44 years to make their own decision about mammographic screening—annual screening, not biennial as recommended by the USPSTF—then undergo annual screening from ages 45 to 54 years, switching to every two years only after age 55 (unless they choose to have annual mammograms) until their life expectancy is less than 10 years. (See http://bit.ly/1bxksKS.)
The guidelines of the American College of Obstetricians and Gynecologists (http://bit.ly/1TpUrac) go even farther than those of the ACS, holding that all women 40 years old and older should receive annual mammographic screening.
The variations can be attributed to different interpretations of data and differing weights assigned to harms and benefits, but the result of those differences is confusion among both patients and providers. Some providers feel the new, looser recommendations are merely an attempt to save money in the wrong places and a step in the wrong direction. “We have preached and promoted, for years, ‘early detection with mammography,’” says Lillie Shockney, administrative director of the Johns Hopkins University (JHU) Breast Center and Cancer Survivorship Programs and associate professor at the JHU School of Medicine and JHU School of Nursing. “And now women are going to believe that mammography annually isn't of benefit. This is despite 23% of women diagnosed being in their 40s.”
Many health care providers continue to recommend annual screening for women in their 40s, and Shockney hopes they continue to stand their ground. “That said, if a nurse is working with a team of clinicians, she or he is going to need to know what the team's position is on this recommendation,” she says, pointing out that a nurse may recommend continuing annual mammographic screening but the facility she or he refers a patient to may decline to perform one if it is following the USPSTF recommendations.
Insurance coverage could upset the scales as well, which the USPSTF acknowledges. The Affordable Care Act mandates that people with private health plans receive coverage without copayment or coinsurance for preventive services that have an A recommendation from the USPSTF (“There is high certainty that the net benefit is substantial”) or a B recommendation, but the task force's C rating could allow insurers to deny payment for screening mammograms. That would create a financial barrier for women in their 40s who believe screening would be beneficial.
Ultimately, says Shockney, the job of the health care provider is to help patients understand the significance of their family history and other risk factors and make informed decisions about screening. To ensure the accuracy of the test results, Shockney also recommends that anyone being screened seek out a breast-imaging facility where there are breast-imaging radiologists—those who have done fellowships specifically in breast imaging—on staff.—Laura Wallis
Siu AL, et al. Ann Intern Med. 2016;164(4):279–96