November 6th, 2015
New American Cancer Society Guidelines for Breast Cancer Screenings Ignore Improvements in Technology, Expose Women to Unnecessary Risk
By Dr. Jonathan Sims, Radiologist and Director of Women’s Imaging at Oregon Imaging Centers
Twelve years’ of aggressive public health service campaigns came into question last month when the American Cancer Society issued confusing new guidelines for breast cancer screenings.
The recommendations surprised even those in the field. They address the age to start mammograms and how frequently to have one; at what age to stop; and whether to use physical breast examinations. By far the most controversial of the recommendations was that women should begin having mammograms at age 45, rather than at 40.
The recommendations have clouded what was previously clear: That women should start annual mammograms at age 40.
As a radiologist specializing in breast imaging, I’m biased; My opinions have been formed by a career of using early detection to save lives. I would far prefer the women I know to have their first mammograms at age 40. That's in part because of information we learned through our own records: From Jan. 1 through Oct. 15, 2015, Oregon Imaging Centers conducted 1,600 mammograms for women under 45. We found 16 invasive cancers – cancers for which surgery was needed before they could become deadly.
The ACS said that call-backs and biopsies were a significant risk when it weighed the risks and benefits of mammography screenings. At Oregon Imaging we know that being called back is scary but sometimes necessary.
Women 40 to 45 years old have some of the highest call back rates of any age group for two reasons. A woman will often be called back on her first screening mammogram because she has no previous exams for comparison. If we raise the age for first mammograms, those women will simply be called back later. The other reason is that women 40 to 45 have not reached menopause, so their breasts are more dense, making detecting cancers harder. Detecting breast cancer in a hormonally active woman is vital, because her hormones may help breast cancer grow.
Another problem with the ACS recommendations is that they are already outdated. Imaging technology has changed rapidly, and current technology was not taken into account by the task force. Specifically, 3D mammography, known in the medical field as digital tomosynthesis, has drastically reduced false alarms and radiation exposure.
When we started using the new machines at our clinics in Eugene and Springfield, the number of call backs plummeted by 40 percent in the first few months. I suspect that when the data are gathered and applied to the next set of recommendations, the ACS will again recommend annual mammograms beginning at age 40.
To add to the confusion, the ACS guidelines are not universal. They say “Women should have the opportunity to begin annual screening between the ages of 40 and 44.” They also warn that the recommendations are for those with the average risk of breast cancer and that they do not address the value of screenings for women with dense breast tissue. (Women 40 to 45 are more likely to have dense breast tissue.) We should hope that insurance companies keep this in mind when forming their coverage guidelines.
Finally, if you decide to follow the ACS guidelines and postpone your first mammogram, don’t assume that an annual clinical examination (the examination that involves palpation and visual examination) will help to catch any issues. The ACS guidelines no longer recommend these exams, and no longer recommend that patients perform breast exams on themselves.
On the bright side, the group that helped form the recommendations kept in mind that it takes time to educate and get women in the habit of annual mammograms. The ACS says that age 40 to 45 is the ideal time for a woman to talk about breast health with her physician. I wholeheartedly agree. Ironically, confusion over the new guidelines might be a catalyst for those important doctor-patient conversations.
Whether this theoretical increase in discussion will prompt women to have a mammogram at the appropriate time remains to be seen, but the consequences can be serious if she doesn’t begin mammograms promptly at 45, when breast cancer becomes more common.
The women’s imaging team at Oregon Imaging Centers – and at many other imaging centers – has referred physicians and women to the ACS guidelines for many years, but with this set of revisions our clinic is reconsidering its stance. The ACS is correct to encourage discussion with your physician, but do your own research as well.
As the ACS acknowledges in its report, each of us has our own idea of how best to weigh risks and benefits. In my opinion, it’s simple: The risk of having a mammogram is mild, but the risk of not having a mammogram could be a matter of life and death.
-- Dr. Jonathan Sims is a radiologist specializing in women’s imaging. He estimates he interprets nearly 4,500 mammograms each year. He is the Director of Women’s Imaging at Oregon Imaging Centers, which performs and evaluates 22,000 mammography studies each year from locations at University District and the RiverBend campus. Oregon Imaging Centers and its 15 radiologists provide a full range of medical imaging services. It is locally owned and operated.