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Recommendations for breast cancer screening in asymptomatic average-risk women vary regarding frequency, age to start and stop, and whether clinical breast examination (CBE) is useful. To develop this guidance statement, the ACP Clinical Guidelines Committee reviewed seven relevant guidelines from U.S. and Canadian professional organizations and the WHO.
For women aged 40 to 49, clinicians should review the pros and cons of mammography before age 50, taking into account patients' preferences. Screening harms outweigh benefits for most women in this age group.
Clinicians should offer biennial mammograms for women aged 50 to 74.
Clinicians should discontinue screening in women aged ≥75 or those with life expectancy ≤10 years.
Regardless of a woman's age, CBE is not a useful approach to screening.
Qaseem A et al. Screening for breast cancer in average-risk women: A guidance statement from the American College of Physicians. Ann Intern Med 2019 Apr 9; [e-pub]. (https://doi.org/10.7326/M18-2147)
Elmore JG and Lee Cl.A guide to a guidance statement on screening guidelines. Ann Intern Med 2019 Apr 9; [e-pub]. (https://doi.org/10.7326/M19-0726)
Comment
The ACP committee noted that, in general, the magnitude of reduction in breast cancer mortality associated with mammography screening is small, a point it believes most guidelines did not emphasize. The guidance statement also points out that most guidelines did not demonstrate any reduction among women aged 39 to 49 (the group that received the least benefit from screening with respect to deaths prevented). Screening in this age group likewise did not reduce the incidence of advanced breast cancer. Regardless of women's age, mammography did not reduce all-cause mortality. In most women aged 40 to 49, screening's harms (overdiagnosis, overtreatment, false-positive results, unnecessary diagnostic testing and biopsies) outweighed its benefits. More-frequent screening was associated with greater harm, and outcomes of annual mammography did not clearly differ from those of longer intervals.
Breast cancer screening remains a fraught subject. While this ACP guidance is targeted to average-risk women, many who are not at excess risk actually perceive their risk as high. I agree with the editorialists that providing clear evidence-based guidance about breast cancer screening (as this statement does) is easier than implementing it, particularly within the time constraints of a well-woman visit.