Updated USPSTF Breast Cancer Screening Guidelines Remain Controversial

The US Preventive Services Task Force (USPSTF) released an updated recommendation for breast cancer screening last week. The recommendations call for an individualized approach to screening mammograms for women less than 50 years of age and biennial screening for women between 50 and 74 years old. However, radiologists and breast cancer specialists disagree with raising the age of screening from 40 years to 50 years.

The updated Recommendation Statement includes the following advice:

1. Biennial screening mammography for women 50 to 74 years old (Grade B)
2. Individualized approach to screening for women between 40 and 49 years old (Grade C)
3. Insufficient data to assess benefits or harm of screening mammography in women over 75 years (Grade I)

According to the USPSTF, screening with film mammography results in an absolute reduction in breast cancer mortality for women between 50 and 74 years old, and the strongest evidence for the greatest benefit is among women 60 to 69 years old.

The Task Force did not find evidence to support reduced mortality as a result of breast self-examination (BSE) or any benefit of digital mammography and MRI of the breast. To the contrary, they found small harms resulting from BSE.

In an opinion piece for Morning Consult, Michelle L, Rivera, MD, a diagnostic radiologist, writes that the absence of a radiologist or a breast cancer specialist on the Task Force bothers her. Taking note of some of the outdated evidence from Sweden and Canada reviewed by the Task Force, Rivera points out, “the largest and longest running breast cancer screening studies in history reconfirm that regular screening cuts breast cancer deaths by roughly a third in all women over age 40—including those aged 40 to 49.”

The American College of Radiology and the Society of Breast Cancer Imaging have issued a joint statement that supports annual mammography screening in women at age 40. “Following these USPSTF recommendations would result in lethal consequences for thousands of women each year,” the statement reads.

Coverage decisions for screening might be at stake if these recommendations pass Congress. The Affordable Care Act mandates private payer coverage for grade “A” and “B” recommendations by the USPSTF, without a copay. So for women younger than 50 years, who have a “C” grade for screening per the current recommendations, may have to bear the cost out-of-pocket, as will women in the 50 to 74 year age group who might prefer an annual examination versus the recommended biennial screen. However, the Protecting Access to Lifesaving Screenings Act or PALS Act, introduced in Congress in July last year, could help protect these women—at least till January 1, 2018. The PALS Act recommends continuing Medicare coverage for screening mammography without coinsurance, including digital screening.

“Women should know what their risk is. Women who are at high risk, for example, who have a genetic mutation that puts them at higher risk for developing breast cancer and who have a very strong family history of breast cancer, should really be talking to their doctors on when they should be starting mammography, and whether they should be having other tests, as well,” said Anees B. Chagpar, MD, director of The Breast Center at Smilow Cancer Hospital at Yale-New Haven, in an interview with OncLive.

Rivera firmly believes in the positive impact of early screening mammography in reducing breast cancer deaths. “We know that women who develop breast cancer between the ages of 40 and 49 often develop more aggressive types of cancer with a worse prognosis,” she writes. “Given all of the data showing that routine screening beginning at age 40 save the most lives, I cannot understand why the USPSTF would deny women a fighting chance.”