SouthernWorldwide.com – A recent shift in breast cancer screening guidelines by the American College of Physicians (ACP) has sparked debate among medical experts, with some expressing concerns that the new recommendations may lead to confusion and potentially impact patient care.
The ACP’s updated guidance, published in the Annals of Internal Medicine, suggests a risk-based approach to mammograms. For women between 50 and 74 years old who are at average risk and asymptomatic, the recommendation is to undergo mammograms every two years.
This differs from the common practice where many women begin their annual mammograms at age 40. The ACP’s guidance encourages women aged 40 to 49 to discuss their individual breast cancer risk with their doctor, carefully considering the potential benefits and harms of screening.
The ACP highlighted that unnecessary screening can lead to several adverse outcomes. These include false positive results, which can cause significant psychological distress. Additionally, over-diagnosis and over-treatment are potential risks, leading to further testing and exposure to radiation.
For women aged 75 and older who are asymptomatic and at average risk, or those with a limited life expectancy, the ACP advises discussing the cessation of screening with their physicians. This recommendation stems from the observation that the benefits of screening may be reduced or uncertain beyond age 74, while the likelihood of harms such as over-diagnosis increases with age.
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In cases of dense breast tissue, the ACP suggests that doctors consider supplemental digital breast tomosynthesis (DBT), commonly known as 3D mammography. However, the organization advises against using supplemental MRI or ultrasound for screening in this population.
The ACP’s Clinical Guidelines Committee defined “average-risk” as individuals without a personal history of breast cancer, a diagnosis of a high-risk breast lesion, BRCA 1 or 2 genetic mutations, a familial breast cancer risk syndrome, or a history of high-dose radiation therapy to the chest at a young age.
Dr. Jason M. Goldman, president of the ACP, emphasized that breast cancer screening is crucial and should be informed by the best available evidence. He stated that the guidance aims to equip physicians and women with the necessary information for making informed decisions about when to start and stop screening, the frequency of screenings, and the most appropriate methods to use.
However, these new recommendations have drawn criticism from some medical professionals. Dr. Lauren Carcas, a medical oncologist at the Miami Cancer Institute, expressed that the guidance “adds to the confusion of screening recommendations.”
Dr. Carcas explained that while a risk-based screening approach is logical, it assumes equal access to individualized discussions and nuanced risk assessments for all women, whether through their primary care or gynecologic physicians. She voiced concerns that these biennial screening recommendations could potentially exacerbate existing disparities and increase the risk of missed cancers in populations already facing barriers to healthcare.
The ACP’s new guidelines stand in contrast to those of other prominent organizations such as the American Society of Breast Surgeons and the American College of Radiology/Society of Breast Imaging. These groups typically advocate for annual mammography screenings, generally starting at age 40.
According to Dr. Carcas, the most significant point of contention among medical societies and the ACP’s task force is the screening interval. She noted that while all major U.S. societies agree that mammography screening should be available from age 40, they also recommend a formal breast cancer risk assessment by age 25 to guide ongoing screening strategies.
Dr. Carcas also challenged the ACP’s stance against supplemental MRI and ultrasounds for women with dense breasts, favoring only DBT. She pointed out that radiology societies strongly recommend the inclusion and consideration of breast ultrasound and/or MRI for more comprehensive and accurate imaging.
For women with a lifetime risk of developing breast cancer of 20% or higher, Dr. Carcas stated they are considered high-risk and should undergo annual screening with the consideration of supplemental ultrasound and MRI. For average-risk women, the decision on screening frequency, whether annual or biennial, should be a nuanced discussion between the patient and her physician, based on individual preferences and medical advice.
Dr. Carcas highlighted a perceived “gap in evidence” regarding mortality risk differences between annual and biennial screening, as there has not been a randomized controlled trial specifically investigating this comparison. She believes that most women diagnosed with breast cancer would prefer earlier detection, which often leads to less aggressive treatment options.
Despite the ACP’s new recommendations, Dr. Carcas indicated that she will continue to recommend annual screenings to her patients and offer ultrasounds and MRIs to those deemed necessary. She expressed hope that the ACP’s guidance will not negatively affect insurance coverage for screening patients, especially given the differing recommendations among various medical societies.
