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Mammograms should start at 40, doctors' group says

Doctors should offer all women in their 40s the chance to get annual screening for breast cancer, according to new guidelines from an organization of women’s health professionals.
/ Source: Reuters

Doctors should offer all women in their 40s the chance to get annual screening for breast cancer, according to new guidelines from an organization of women’s health professionals.

The recommendations, from the American College of Obstetricians and Gynecologists (ACOG), are the latest addition to a hot debate over when screening should start, and how often it should be done -- based on the chances of catching an early cancer and the risks inherent in any screening.

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“We believe it is our job to help women make the best health decision for themselves,” said Dr. Jennifer Griffin of the University of Nebraska Medical Center in Omaha, one of the authors of the new recommendations.

“We believe that many women will choose to have a screening mammogram every year, (and) of course there are women that will choose not to.”

Other organizations such as the American Cancer Society and the National Comprehensive Cancer Network recommend women start getting the breast scans at age 40. But the U.S. Preventive Services Task Force, a federally-supported expert panel, said in 2009 that screening before 50 should be an individual decision, because the benefit is very small compared with the risks.

And even at age 50, it only recommended screening every other year.

Dr. Michael LeFevre, from the USPSTF, said that any screening decision is about balancing the benefits and harms of a test.

One in eight women will get breast cancer during her life, experts agree.

Of every 1,000 40-year-old women, LeFevre said, 30 would be expected to ultimately die of breast cancer if they never have a mammogram.

If those 1,000 women are screened every other year between age 50 and 75, that number drops to 23 deaths. Starting screening in the same group at 40 instead would save one additional life, meaning 22 would die of breast cancer, on average.

But, LeFevre told Reuters Health, “that small benefit comes with a significant false positive rate, which results in additional testing, including unnecessary biopsies and associated pain and anxiety.”

Half of women screened annually in their 40s will have a false alarm on a mammogram, he said -- meaning the test shows something suspicious that turns out to be harmless. Follow-up biopsies can be painful, expensive and carry a small risk of infections or other adverse effects.

With his patients, LeFevre said, “my bottom line is that I will discuss mammography at age 40, I will recommend and encourage at age 50 and I will strongly encourage at age 60.”

At age 75, he said, the science starts to run out that screening’s benefits are greater than its harms.

He added that screening every other year, instead of annually, gives women most of the benefit of yearly mammograms but significantly cuts back on the risk of harm.

The new guidelines only apply to women who are at average risk of breast cancer -- not those with a gene that predisposes them to the disease, for example.

ACOG also recommends that doctors perform regular breast exams on women and says that women should know what their breasts normally look and feel like.

“As with any screening test, there are cancers that are missed by screening,” Griffin said. “Women should be aware that if something changes in their breast, even if they’ve had a normal screening mammogram, they should let their doctors know.”

LeFevre said there isn’t clear evidence that “breast awareness” can prevent breast cancer deaths, but that he wouldn’t discourage it.

The ACOG group didn’t analyze the cost of screening women for an extra decade, but Griffin said that mammograms compare favorably to other screening tests, such as Pap smears and colonoscopies, in their cost-effectiveness. Mammograms typically cost about $100, but in most cases are covered by insurance.

Groups including the American College of Radiology, the Society of Breast Imaging and Susan G. Komen for the Cure came out in support of the new guidelines.

“When we think about women in their 40s we think about moms, we think about women who are active in the workforce,” Griffin said. “I think they deserve the opportunity to really benefit from this test.”

LeFevre concluded that women in their 40s should discuss the possible benefits and harms of mammography screening with their own doctors, and make a personal decision about when to start getting screened.