A Mammogram Update: New Breast Cancer Screening Guidelines

Back in May 2015 I wrote a post entitled Moms, Get Your Mammograms.   I gave some (hopefully!) clear advice about when to obtain a first (baseline) mammogram and when to get clinical and self breast exams, because the information out there is confusing.  It’s conflicting.  Even the medical community grapples repeatedly with the when-and-how-often of screening.  And they have done it again:  in October of 2015, the American Cancer Society (ACS) released an updated set of guidelines regarding breast cancer screening.   So I’d like to share with you some of the new recommendations, focusing on the information we women approaching, and already into, our 40’s need to know.

Starting at age 45, the ACS recommends women at average risk for breast cancer undergo yearly mammograms until the age of 55 (when every-other-year screening should begin).  The ACS guidelines previously stated that women should get a baseline mammogram at age 40.

However, women should be given the choice to start annual mammograms between the ages of 40 and 44 years.  At 40, women should discuss with their medical providers 1) the risks and benefits of obtaining a mammogram before the recommended age of 45, and 2) personal health and family history to aid in determining risk for breast cancer, which may (or may not) establish a need to begin mammograms earlier than the new recommended age of 45.

Clinical breast examination (CBE), or a physical breast exam conducted by a medical professional, is not recommended for any woman at average-risk for developing breast cancer.  Previously, the CBE was endorsed by the ACS.

The self breast exam (SBE or BSE) is optional.

Generally speaking, the guidelines are arrived at through large-scale reviews of medical research.  And if you are a woman wondering whether to get your first mammogram at age 40 or at 45,  your practitioner will ask you some questions about your personal health history, as well as your family’s history of breast cancer.  Hopefully, you will be in the average risk category.  (Yes, here it is good to be “average,”  as there is no “low-risk” designation.)  In that case, your practitioner may share some information with you to help you make an informed decision about when to obtain your first mammogram.  Here are some relevant points:

•Mammography is less accurate in women under the age of 45.

•The highest false positive rate for mammography studies (meaning the discovery of suspicious findings that turn out to not be cancerous) is highest in women in their 40’s.  And the only way to pin down a potential problem is to do further “views” with a mammogram, or do a biopsy (or both) which takes time and money, is emotionally stressful, and is costly and time-consuming.

•However, most research shows a decreased death rate overall from breast cancer if screening mammography starts at age 40.

Not terribly helpful info, is it?  No wonder the guidelines change, and no wonder individual medical practitioners, physician groups and task forces cannot agree on when women should get mammograms.***

But here’s my two cents worth.  If I were in practice as a physician assistant today, taking into account the new and variable opinions regarding when to get a baseline mammogram, here’s what I would tell my female patients:

Age 40.  Get your first mammogram at age 40.

I will admit this is not a purely clinical and academic decision on my part.  The art of medicine allows for experience, and even that “gut feeling” to play a role in how we care for people.  And admittedly, emotions can play a part as well, but need to be carefully considered.  As of this writing, I  know eight women, all of whom in their 30’s or 40’s, who have faced breast cancer.  These are not women I have known as patients, so there is no “selection bias” involved.  All are women I know outside of an examination room.  And I know more who have a strong family history (mothers and sisters) of breast cancer who are at high risk for the disease.  Yes, breast cancer primarily strikes “older” women but I can’t in good conscience ignore the fact that “younger” women are diagnosed as well.  So I say:  get that first mammo when you turn 40.

I realize that women in their 40’s are at high risk of a “false alarm,” a finding on a mammogram (or by a self or clinical exam) that turns out to be “nothing” and that this process puts women through a lot.  It’s scary.  Believe me, as someone who has had a couple false alarms herself, I fully understand that awful experience.  But to be perfectly honest…I’d rather deal with that emotional burden than wait five years, get my first mammogram, and have the results show  a cancer that has had several years to grow undetected.

So talk with your medical practitioner when you turn 40.  Ask questions and answer theirs. If you are past 40, do the same; it’s never too late to have a dialogue about breast cancer screening.

As for the clinical and self breast exams?  Here’s what I think (now):

If a woman asked for a clinical breast exam, I’d do it.

I’d say doing a self exam is her choice.

When I was in training, I was taught to complete clinical exams and educate women in doing self exams….but recommendations change.  As the research accumulates and points in a different direction, what medical practitioners do as a part of good care also changes.  But here’s the thing:  it’s your choice to consider a mammogram at age 40, so it is your choice to consider the clinical and self breast exams as well.  Talk with your medical practitioner and decide together what is best for you.

Like to learn more?  This is a great article from the American Cancer Society:

http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs

***While there is disagreement about when to start getting mammograms, one thing is for sure:  all medical practitioners and organizations believe mammograms are important in the breast cancer screening process.