The new American College of Physicians guidelines for mammography screening set the breast imaging community on a tilt and have patients vying for answers. by Kori Graddy


According to the new guidelines from the American College of Physicians, decisions about whether women aged 40 to 49 undergo screening mammography should be based on patients' concerns about mammograms and breast cancer as well as their risk for the disease.

ACP stated that the “clinical guidelines are developed in an explicit, rigorous process based on extensive review of available scientific evidence and are considered ‘evidence-based’ rather than ‘expert-opinion’ or ‘consensus guidelines’”. During this process the ACP reviewed 117 studies to evaluate the evidence about the risks and benefits of mammography screening for women between the ages of 40 and 49.

These guidelines are published in Annals of Internal Medicine.

In these guidelines, recommended screening for patients in their 40s was non-existent and suggested that such women should consult their physician to determine when screening should take place and that screening decisions should be individualized, based on assessments of their risk for breast cancer.

It also suggests clinicians should inform women in this age group about the potential benefits and harms of screening mammography.

In the 117 evaluated studies, the ACP did not include the recently published Cochrane Collaboration review or the age randomized trial conducted by Moss SM, Cuckle H, Evans A, Johns L, Waller M, Bobrow L, et al, which is designed to determine whether screening women in their 40s is associated with a reduction in breast cancer mortality.

The ACP states that there are obvious benefits to screening women over 50; however, the clinical evidence is not robust enough to recommend screening in the population of younger women in their 40s.

In the same time frame of the released guidelines from the American College of Physicians, numerous studies and advisories were released that may have women questioning the legitimate concern of their healthcare practitioner, as well as themselves on which direction to take in the pursuit of health. This on the heels of a ‘Get screened’ and ‘Screening is everything’ motto promoted by many public health societies.

On the other hand, after reviewing new study evidence that has become available, the American Cancer Society (ACS) recently announced that an expert panel organized by the ACS has developed new recommendations and promotes the use of magnetic resonance imaging for women at increased risk for breast cancer, and recommends annual screening using MRI in addition to mammography.

The advised ACS guidelines for the early detection of breast cancer were last issued in 2003, at which time the ACS states “there was insufficient evidence to justify a recommendation to use MRI to screen for breast cancer”. The ACS article and guidelines are published in the March/April 2007 issue of CA: A Cancer Journal for Clinicians, a peer-reviewed journal of the American Cancer Society.

However, in a recent study conducted by Dr. Constance Lehman et al. titled MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer, contralateral breast cancer was detected in about 3 per cent of women in the absence of clinical or mammographic findings.

We know that within certain patient populations, magnetic resonance imaging is more sensitive than mammography for detecting breast cancer but sometimes leads to false-positives resulting in numerous biopsies of benign lesions.

In the multicenter study that included 25 US sites and 969 patients Dr. Lehman and researchers examined the role of contralateral breast magnetic resonance imaging in women with recently diagnosed breast cancer who had had normal clinical and no abnormalities or mammographic findings in the contralateral breast within 90 days of study enrollment.

In this study MRI detected clinically and mammographically occult breast cancer in the contralateral breast in 30 of 969 women that were enrolled in the study group. The sensitivity of MRI in the contralateral breast was 91 per cent with 3 false-negatives, and the specificity was 88 per cent with 114 false-positives.

Dr. Lehmans’ study concluded that MRI can detect cancer in the contralateral breast that is missed by mammography and clinical examination at the time of the initial breast-cancer diagnosis. The mean age of the 969 women was 53 years of age with no family history of breast cancer.

Despite the new guidelines and recommendations, Susan G. Komen for the Cure remains firm that women in the 40 to 49 year age group continue to undergo yearly screening mammograms to reduce their risk of dying of breast cancer.

In a recent statement, senior clinical advisor for Susan G. Komen for the Cure, Cheryl Perkins, M.D said, "Komen for the Cure feels that the modest survival benefits of mammography in this age group outweigh the risks of false positive results, and they recommend regular mammograms for women ages 40 to 49”.

However, they also mentioned, “There is a concern that the guidelines could cause confusion for women about the value of annual mammograms. Randomized controlled trials have shown that women 40 to 49 who get regular mammograms can lower their risk of dying from breast cancer by 15 to 20 per cent, compared to the 25 to 30 per cent lower risk seen in women ages 50 to 69”.