Updated Mammogram Screening Guidelines for Preventative Breast Cancer Screening

By Dr. Douglas Blayney, Manta Cares Chief Medical Officer

The US Preventive Services Task Force (USPSTF) has updated their mammogram screening guideline for preventative breast cancer screening.  For women of average risk, the USPSTF now recommends that all women get screened for breast cancer every other year starting at age 40 and continuing through age 74 Recommendation: Breast Cancer: Screening | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org).  Other recognized expert bodies also recommend starting screening at age 40.  The American Cancer Society (ACS) Cancer Screening Guidelines | Detecting Cancer Early | American Cancer Society also recommends women have the option of starting screening at age 40, and sets the interval at every year starting at age 44, and then every other year after age 55.  The NCCN also recommends average risk women begin yearly screening at age 40 along with yearly breast exams by a physician and monthly breast self exams.  The NCCN also recommends high risk women begin screening as early as age 30 NCCN Guidelines for Patients: Breast Cancer Screening and Diagnosis.

The differences among the various expert opinions reflect well known uncertainty about the evidence behind the recommendations. 

Several caveats from my viewpoint:

1.  For women with dense breasts, a mammogram is a good but not great test.  A mammogram detects the difference in x-ray transmission between two contrasting tissues. Mammograms are best at detecting the difference between fat tissue and other tissues, such as calcium, cancer, cartilage, muscle, connective tissue and milk secreting gland tissue.  As a result, mammograms are more reliable in women with more fat in their breasts – which is a normal result of aging–than in women with less fat. Young women usually have less fat and more connective tissue and milk secreting gland tissue in their breasts. These two tissue types do not have as much contrast with cancer tissue and calcium, and can hide or make cancer tissue in a mammogram difficult to detect.
2. In many states, including California, the mammogram report is required to note if the woman has dense breasts, and may benefit from further screening. Breast MRIs and ultrasound do not have the same x-ray related limitations as mammography, and are alternative screening methods. Both MRI and ultrasound are more labor intensive and expensive than a mammogram, take more time, and have other limitations, which is why neither are recommended for routine screening.
3. Finally, if a woman (or man) has a mass in their breast which doesn’t disappear completely after about one month, a normal mammogram should not be interpreted as “no cancer.” Persisting breast masses with a normal mammogram should have an ultrasound or an MRI by an experienced radiology team to provide reassurance that there is not cancer.
4. As always, if there is uncertainty, a woman should discuss with her doctor about her individual breast cancer risk, and when and how to start screening with a mammogram or another test.

In summary, mammogram screening has been a great contributor to the reduction in breast cancer deaths seen in the last fifty years. However, we need screening strategies more tailored to the individual woman. More accurate strategies will reduce false positive test (for example when a mammogram is abnormal, and no cancer is found after a biopsy), and false negatives (for example a normal mammogram in which a small cancer is later found).

By the way, the USPSTF is an independent, volunteer panel of national experts in prevention and evidence-based medicine that works to improve the health of people nationwide by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications.

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