Screening nowadays became a prevalent method for early detection of predisposition to certain diseases. It is highly beneficial for patients as it helps to reduce the risk of illness and receive timely treatment. Although health workers widely recognize the effectiveness of screening, they emphasize that unneeded additional testing can harm people who are not at risk. Therefore, the medical practitioner, who recommends a screening, should take into account factors like appropriate time (intervals) for screening, age, general health, and medical history. This paper aims to give a proper recommendation for breast cancer screening under USPSTF guidelines while considering the differences in patients’ epidemiology.
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USPSTF Guidelines for Breast Cancer Screening
Recommendations for screening for breast cancer are the most diversified compared to screening recommendations for other diseases. USPSTF guidelines, updated in 2016, recommend biennial screening mammography as a screening method for women aged 50 to 74 years. At the same time, women younger than 50 years old should themselves decide whether to pass the mammography screening or not.
Women who see more potential benefits than potential harms may choose to begin biennial screening between the ages of 40 and 49 years. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older. Besides, USPSTF does not have a clear recommendation considering the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer.
Critics Regarding Age and Risks: Key Evidence
Some research findings support the validity of the USPSTF guidelines recommendation. According to a study by Mandelblatt et al. (2016), for women with moderate risk, biennial screening is recommended. Annual screening for groups aged 50-74 was found to be ineffective due to the equal positive effect and greater harm. Whereas, for high-risk groups, annual screening from age 40 years had similar harms and benefits as screening average-risk women biennially from 50 to 74 years. Besides, scientists recommend stopping the screening at the age of 66-68 years for groups with moderate or severe comorbidity.
Authors emphasize that “decisions about starting ages and intervals will depend on population characteristics and the decision-makers weight given to the harms and benefits of screening” (Mandelblatt et al., 2016, p. 215). Among the main harms of screening are false-positive mammograms, benign biopsies, and overdiagnoses. The effect of overdiagnosis on QALYs (Quality Adjusted Life Year) emerged when the patient was treated for cancer but died of other causes. Benign biopsies were defined as biopsies among women with false-positive screening results. Abnormal mammograms or those needing further diagnostic were considered false-positive mammograms.
Some scientists draw attention to the significant inconsistency of recommendations for breast cancer screening (Onega et al., 2017). As mentioned above, the USPSTF recommends that the first mammogram should be made at the age of 50 and considers the optimal interval between mammograms to be two years. But ACR (American College of Radiology) and ACS (American Cancer Society) advise having the first screening mammogram at the age of 40.
These organizations do not specify the age when the screening should be stopped and consider annual screening as the optimal one. It should be mentioned that the Department of Health and Human Services is still applying the 2002 recommendation, according to which screening mammography is recommended for women age 40 years and older, with or without clinical breast examination every 1 to 2 years.
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Critics Regarding Biennial Screening Interval
Other scientists are worried about the new guidelines for a different reason. According to Mehta et al. (2019), the introduction of the USPSTF updated recommendations for biennial screening had its influence on patients. Scientists are concerned since they believe there is a lack of evidence. Mehta et al. (2019) note that “before the revision, 76% thought that annual mammography was needed for routine screening” (p. 302). And after revising the guidelines, the percentage of women who planned to continue their annual mammograms dropped significantly to 64%. Scientists also emphasize that, according to 48% of participants, the most important reason for changing the guidelines was a reduction in governmental health care expenses.
Risk Factors and Risk Assessment Methodology
USPSTF, as well as ACR and ACS, recommend discussing screening necessity with patients aged 40 to 49 years and their service providers based on patient risks and preferences. Moreover, according to a study by Van Den Broek et al. (2018), screening among women aged 40 to 49 caused a decrease in mortality by an average of 15% if a disease was detected in the intervention phase. According to scientists, this is a highly sufficient argument for screening women of this age group.
According to Gierach, Choudhury, and García-Closas (2019), approaches for identifying women at increased risk include the use of “risk prediction models with pedigree-level family history information and genetic testing.” Authors note that routine screening is recommended for women with an average risk of age 40-50. Whereas enhanced screening is optimal for younger women with increased risk (Gierach et al., 2019). The increased risk is mainly associated with heredity (anamnesis) or a predisposition to genetic mutations.
Thus, an optimal recommendation for breast cancer screening under USPSTF guidelines should be given as follows. Biennial mammography screening will be appropriate for women aged 40-74 with average risk factors, and annual mammography screening will suit women aged 40-50 and younger with increased risk. While making the decision, a medical practitioner should discuss it with patients of all ages and risk groups and explain to them the potential harms and benefits of mammography screening.
Gierach, G. L., Choudhury, P. P., & García-Closas, M. (2019). Toward risk-stratified breast cancer screening: Considerations for changes in screening guidelines. JAMA Oncology. Web.
Mandelblatt, J. S., Stout, N. K., Schechter, C. B., Van Den Broek, J. J., Miglioretti, D. L., Krapcho, M.,… Van Ravesteyn, N. T. (2016). Collaborative modeling of the benefits and harms associated with different US breast cancer screening strategies. Annals of Internal Medicine, 164(4), 215-225.
Mehta, J. M., MacLaughlin, K. L., Millstine, D. M., Faubion, S. S., Wallace, M. R., Shah, A. A.,… Temkit, M. H. (2019). Breast cancer screening: Women’s attitudes and beliefs in light of updated United States Preventive Services Task Force and American Cancer Society guidelines. Journal of Women’s Health, 28(3), 302-313.
Onega, T., Haas, J. S., Bitton, A., Brackett, C., Weiss, J., Goodrich, M.,… Tosteson, A. N. (2017). Alignment of breast cancer screening guidelines, accountability metrics, and practice patterns. The American Journal of Managed Care, 23(1), 35-40.
Van Den Broek, J. J., Van Ravesteyn, N. T., Mandelblatt, J. S., Huang, H., Ergun, M. A., Burnside, E. S.,… Stout, N. K. (2018). Comparing CISNET breast cancer incidence and mortality predictions to observed clinical trial results of mammography screening from ages 40 to 49. Medical Decision Making. Web.