27 Oct 2015

New Mammogram Guidelines?

Earlier this month the American Cancer Society(ACS) published new guidelines regarding screening mammography for women. They have advised that women without known risk factors start mammograms at age 45 (up from 40) and that after age 55, a mammogram should only be done every two years.

The rationale behind advising fewer mammograms is that by starting earlier and continuing annual mammograms in older patients will result in more false positive results. A false positive result is when the mammogram indicates a possible cancer, which is subsequently (usually following a biopsy), shown to not be a cancer. The ACS publishers claim that false positives lead to undue anxiety and unnecessary biopsy tests in patients. Since breast cancers are less frequent in patients younger than 45 and agressive (fast growing) cancers are less frequent in older patients, they rationalise that picking up a few extra cancers in those groups does not warrant the extra number of false positive results and associated anxiety/interventional tests.

The American College of Radiology, The American College of Obstetricians and Gynecologists and the Society of Breast Imaging all maintain the original guidelines of starting screening mammograms at age 40 and continuing with annual mammograms regardless of age.

Anecdotally, at our practice, a substantial proportion of the breast cancers seen are in the younger age group (35 - 45). These patients often have more aggressive cancers and they usually present a bit later since they are not having annual mammograms and not suspecting breast cancer.

Breast cancer most certainly increases with age, although it is true that older patients often have slower growing tumors. Nonetheless, in the last two months, we have seen 5 new cancers in women aged 75 - 85. Mammograms and biopsies are well tolerated in even frail and elderly patients, and breast cancer management has evolved to a level where treatment is tailored (and appropriate) for each patient. In most cases, the older patients, even with other chronic illnesses, easily cope with treatment. Generally, they are treated as conservatively as possible - minimal surgery, limited or no chemotherapy/radiation therapy and sometimes only anti-hormone drugs (eg Tamoxifen) are enough. 

Therefore, in my opinion, starting mammograms at 40 and continuing every year regardless of age, makes the most sense if we wish to detect cancer early and get the most effective traetment for patients. I think we should be very careful when looking at the reasons certain groups are limiting access to this screening test. Is supposed anxiety or an unnecessary biopsy reason enough? What do most patients REALLY want? Where does health budget constraints come into the drive to reduce these life-saving tests come into it?

Some perspective provided in this Washington Post article: