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American College of Physicians: mammography every 2 years between the ages 50 and 74 years
Clinical Question
According to the American College of Physicians, how often should women at average risk be screened for breast cancer?
Bottom line
Citing that the harms of screening (false-positive results, benign biopsies, and overdiagnosis) outweigh the benefits of early diagnosis, the American College of Physicians (ACP) does not recommend routine screening of women between the ages of 40 years and 49 years; instead, the group suggests a discussion based on an overview of benefits and harms. Women aged 50 to 74 years should be offered screening every 2 years, stopping if they have a life expectancy of less than 10 years. Stop screening at age 75. If you haven't already, drop the clinical breast examination. 5
Reference
Study design: Practice guideline
Funding: Foundation
Setting: Outpatient (any)
Synopsis
This statement starts with available guidelines that conflict with one another and scores them for validity using the AGREE II instrument, a guide for producing high-quality guidelines. The guideline development committee comprised members of the ACP and 2 public representatives without conflicts of interest. The resulting guidance was reviewed by the governance of the ACP. The committee scored several guidelines as low-quality based on methodology that did not have a formal means of linking benefits and harms with their recommendations or that based recommendations on observational or modeling studies to a greater extent than randomized controlled studies. Said by many but worth repeating: No studies have demonstrated a reduction in all-cause mortality with screening. Breast cancer–related mortality is reduced in women aged 50 to 69 years and 2 guidelines assert benefit for women 39 to 49 years of age. False-positive results leading to additional testing and unneeded treatment (overdiagnosis) are present in all groups, tempering benefit in women younger than 50. No studies have shown a benefit to clinical breast examination.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
Estimating life expectancy for older patients
Will artificial intelligence offer us some help?
re: American College of Physicians mammography recommendations
The American College of Physicians' recommendations are based on outdated studies. Like the US Preventative Services Task Force, they excluded modern observational studies that show 40-60% mortality reduction starting at age 40, for women who participate in mammography. The RCTs they included in their analysis were done between the 1960s and early 1990s, using film mammography that is now obsolete. They exaggerate the risks, citing anxiety from recalls and "over diagnosis." In fact, over diagnosis is less a factor in younger women, since they have fewer co-morbidities than older women. And more quality-adjusted life years are saved when cancer is diagnosed early in younger women.
Women would prefer some transient anxiety to advanced cancer. And in addition to mortality reduction, women clearly prefer less surgery, less lymphedema, and less chemotherapy made possible by early detection (the committee did not consider these options since they are not determined by RCTs).
The most lives are saved by annual screening starting at age 40. And early detection allows less aggressive therapy. Supplemental screening for women with dense breasts will lead to earlier detection in this group of women not as well-served by mammography alone. Women should be allowed to make informed decisions about screening, using contemporary information.
Coldman A et al. Pan-Canadian study of mammography screening and mortality from breast cancer. J Natl Cancer Inst. 2014 Oct 1;106(11)
Tabar L et al. The incidence of fatal breast cancer measures the increased effectiveness of therapy in women participating in mammography screening. Cancer. 2019 Feb 15;125(4):515-523
Ahn S et al. Impact of Screening Mammography on Treatment in Women Diagnosed with Breast Cancer Ann Surg Oncol 2018; 25:2979-86
www.densebreast-info.org
Paula B Gordon, OBC, MD, FRCPC, FSBI
Clinical Professor, UBC