From the Journals

ACOG recommends women start mammography between ages 40 and 50 years


 

Woman at average risk for breast cancer should be offered their first screening mammogram at age 40, with initiation of screening beginning no later than age 50, according to new recommendations from the American College of Obstetricians and Gynecologists.

ACOG suggested a screening interval of 1-2 years based on patient values and preferences.

Dr. Ritu Salani of Ohio State University, Columbus

Dr. Ritu Salani

“Biennial screening mammography, particularly after age 55 years, is a reasonable option to reduce the frequency of harms, as long as patient counseling includes a discussion that with decreased screening comes some reduction in benefits,” ACOG advised in a Practice Bulletin issued on June 22 (Obstet Gynecol 2017;130:e1–16).

Screening should continue until at least age 75 years. Past that age, continuation should be considered in terms of the patient’s overall health and expected lifespan, according to the Practice Bulletin.

Nurse positioning patient for mammogram ©John Foxx/Thinkstockphotos
The new ACOG recommendations for breast cancer screening in average-risk women put a heavy emphasis on flexibility and shared decision-making.

That’s a welcome approach, according to Ritu Salani, MD, a gynecologic oncologist at the Ohio State University, Columbus. “I do believe the ACOG guidelines have the most flexibility and are probably the most comprehensive for average-risk patients,” said Dr. Salani, MD, who was not involved in the drafting of the guidelines.

The recommendations are based in part on a review of existing recommendations from the U.S. Preventive Services Task Force, the American Cancer Society, and the National Comprehensive Cancer Network.

Mammography recommendations in average-risk women
Variation among the existing guidelines has created confusion for women and physicians. For instance, the U.S. Preventive Services Task Force generally recommends initiation of mammography at age 50 years but also says that the decision to start between ages 40-49 should be an individual one. The American Cancer Society says first mammography can be offered at ages 40-45 years, but recommends initiation at age 45 years, while the National Comprehensive Cancer Network calls for initiation at age 40 years. There is also variation among the groups about whether screening should be annual or biennial.

“For patients anxious about developing cancer, maybe every year would be appropriate. When you talk to patients, you have a sense of what would be beneficial for them,” said Dr. Salani, who applauded the flexibility built into the new ACOG guidelines, which says the screening interval can be annual or biennial. “It caters to shared decision-making, and that’s a nice way to frame it.”

The ACOG guidelines recommend against breast self examination because this practice carries the risk of false positives and lacks supporting evidence of benefit. But, ACOG encourages “breast self-awareness,” which means being “attuned to noticing a change or potential problem with her breasts” but without the routine examination.

Women who are asymptomatic and at average risk can be offered clinical breast examination as a screening tool, but clinicians should explain the “uncertainty of additional benefits and the possibility of adverse consequences of clinical breast examination beyond screening mammography.” If performed, ACOG recommends intervals of 1-3 years for women aged 25-39 years and annually for women aged 40 years and over.

The recommendations apply to average-risk women. To help determine risk, the Practice Bulletin also lays out a series of breast cancer risk factors that should be considered, including family history of cancer, known germline mutations, prior biopsy findings, early menarche, late menopause, breast density, and a range of lifestyle and other factors.

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