Breast cancer Screening options include mammograms, family history, genetic
testing, and MRIs. There is considerable controversy about the most appropriate
ages and frequency for mammograms, and decisions should be individualized according
to family history and other risk factors after a consultation and discussion
with a health care provider. Mammography may miss some cancers and result in
false-negatives. False-positives can lead to unnecessary anxiety, additional testing,
and unnecessary biopsies.

Some breast cancers can develop and spread rapidly between mammograms, so
early detection does not work well to prevent illness and death from them. Other
breast cancers, called ductal carcinoma in situ (DCIS) may stay small and local, but
there is no good way to know if they would not cause problems, so these cancers
are also treated. Recently there has been a movement to follow up routine mammography
screening among women with dense breasts with MRI studies because
tumors are more difficult to detect in dense breasts. This practice detects more cancers
but also increases the risk of biopsies when cancer is not present, and it is not
known if the cancers needed to be found and treated to prevent illness and prolong
life. Advocacy groups such as the Susan G. Kommen Foundation have generally
advocated more frequent screening than the National Institutes of Health or the U.
S. Preventative Services Task Force (USPSTF), expert bodies that have expressed
concern about overtesting, overdiagnosis and overtreatment.

One reason screening recommendations may differ is that better evidence is needed
to help women make screening decisions. For example, some breast cancer experts
do not think it is certain that annual rather than biannual screening decreases breast
cancer mortality. Some data suggests that annual screening may be more appropriate
for premenopausal women because earlier diagnosis will help this group of
women who are more likely to have tumors with less favorable prognostic characteristics.

A key component of both ACS and USPSTF recommendations is that screening
decisions should be individualized to reflect a woman’s values and preferences
as well as breast cancer risk. However, considering the high level of publicity,
emotion, and fears about cancer (especially about breast cancer), evidence-based
decision-making may be difficult for medical practitioners and even more so for
individual women. As Rosenbaum has noted in commenting on decisions about
mammography, “…it is as much our job to figure out how to best help our patients
lead healthier lives as it is to honor their preferences.”

A simplified version of the 2015 ACS recommendations for women at average risk
is:
• Women ages 40 to 44 should have the choice to start annual breast cancer
screening with mammograms if they wish to do so. The risks of screening, as
well as the potential benefits, should be considered.
• Women age 45 to 54 should get mammograms every year.
• Women age 55 and older should switch to mammograms every two years, or,
have the choice to continue yearly screening.

The American College of Obstetrics and Gynecology (ACOG), as of June 2017, has
a different recommendation for women at average risk:
• ACOG recommends that women and their obstetrician/gynecologists engage
in a dialogue that includes a discussion of the woman’s health history, the
benefits and harms of screening, and the woman’s concerns, priorities, values,
and preferences about the potential benefits and harms of screening.
• Annual or biannual mammograms beginning at age 40 until at least age 75
with the decision to discontinue screening mammography based on a shared
decision-making process informed by the woman’s health status and
longevity.
Additional resources are available at http://www.acog.org/Womens-Health/
Breast-Cancer-Screening.

The U. S. Preventative Services Task Force also has a different recommendation:
• For women at average risk begin routine screening at age 50
• Biennial screening mammography for women aged 50 to 74 years
USPSTF recommendations say: “While screening mammography in women aged
40 to 49 years may reduce the risk for breast cancer death, the number of deaths
averted is smaller than that in older women and the number of false-positive results
and unnecessary biopsies is larger. The balance of benefits and harms is likely to
improve as women move from their early to late 40s,” and notes that “In addition
to false-positive results and unnecessary biopsies, all women undergoing regular
screening mammography are at risk for the diagnosis and treatment of noninvasive
and invasive breast cancer that would otherwise not have become a threat to their
health, or even apparent, during their lifetime (known as ‘overdiagnosis’). Beginning
mammography screening at a younger age and screening more frequently may
increase the risk for overdiagnosis and subsequent overtreatment.”

The USPSTF recommends counseling, risk assessment, and after evaluation, the
testing of women with a personal, or family history, or ancestry (e.g., Ashkenazi
Jewish ancestry where risk is one in 40), of breast, ovarian or peritoneal cancer associated
with BRCA1/2 gene mutations. The USPSTF recommends against routine
risk assessment, genetic counseling, or genetic testing for women whose personal or
family history or ancestry is not associated with potentially harmful BRCA1/2 gene
mutations.

This blog presents opinions and ideas and is intended to provide helpful general information. I am not engaged in rendering advice or services to the individual reader. The ideas, procedures and suggestions in that are presented are not in any way a substitute for the advice and care of the reader’s own physician or other medical professional based on the reader’s own individual conditions, symptoms or concerns. If the reader needs personal medical, health, dietary, exercise or other assistance or advice the reader should consult a physician and/or other qualified health professionals. The author specifically disclaims all responsibility for any injury, damage or loss that the reader may incur as a direct or indirect consequence of following any directions or suggestions given in this blog or participating in any programs described in this blog or in the book, The Building Blocks of Health––How to Optimize Your Health with a Lifestyle Checklist (available in print or downloaded at Amazon, Apple, Barnes and Noble and elsewhere). Copyright 2021 by J. Joseph Speidel.