Q&A: USPSTF Final Breast Cancer Screening Recommendations

The U.S. Preventive Services Task Force (USPSTF) has issued its final recommendations for breast cancer screening, which include confirmation that screening mammography every two years among women aged 40 to 74 is effective in reducing deaths due to breast cancer, with the greatest benefit seen among women aged 50 to 74.

While the findings are similar to those from 2009, the new guidelines include new considerations regarding additional screening for women with dense breast tissue with normal screening mammograms, as well as the use of digital breast tomosynthesis (3D mammography) in screening.

Diagnostic Imaging interviewed Task Force Chairperson Kirsten Bibbins-Domingo, PhD, MD, MAS, about the newest guidelines and their implications for patients and physicians.

Why were these new guidelines necessary?

As part of the normal process, the Task Force routinely updates recommendations so that they are as current as possible, aiming to update topics approximately every five years. Since the Task Force last made a breast cancer screening recommendation in 2009, it was time for the Task Force to review the evidence and issue a new recommendation.

How do they differ from the most recent guidelines?[[{"type":"media","view_mode":"media_crop","fid":"44800","attributes":{"alt":"Kirsten Bibbins-Domingo, PhD, MD, MAS","class":"media-image media-image-right","id":"media_crop_5500506061719","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5046","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 209px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Kirsten Bibbins-Domingo, PhD, MD, MAS","typeof":"foaf:Image"}}]]

For the first time, the Task Force looked at the effectiveness of digital breast tomosynthesis as a way to screen for breast cancer. While 3D mammography is an emerging technology, there is very little evidence available that examines the ultimate effectiveness of this newer screening method and therefore, the Task Force was unable to make a recommendation for or against its use. This is also the first time that the Task Force looked at the effectiveness of additional screening for women who have known dense breasts but an otherwise negative mammogram. The evidence on how additional screening with an ultrasound, MRI, or 3D mammography may or may not help women with dense breasts is unclear. Therefore, the Task Force cannot make a recommendation for or against additional screening. These are all important areas for future research.

Are the guidelines the same for all density of breast tissue?

The Task Force commissioned a separate evidence review that examined the effectiveness of additional breast cancer screening in women who have or are found to have dense breasts. Unfortunately, the evidence on how additional screening with an ultrasound, MRI, or 3D mammography may or may not help women with dense breasts is unclear, and the Task Force issued an “I statement. “The Task Force hopes that, in the future, there will be more evidence available so that they can make a more definitive recommendation on this important issue that we know impacts many women.

Whenever new proposals, such as screening for breast cancer every two years, are released, some women whose cancers were detected by annual screening are concerned because they believe that their annual screening saved their life. What would you say to them?

We understand that upon learning of a cancer diagnosis, there is a strong desire to treat or remove the cancer, regardless of potential harms of treatment. However, sometimes this course of action can cause more harm than good, because the cancer would never have posed a threat to a woman’s health. Currently, it is not possible to know for any individual woman whether or not her cancer will progress. As a result, almost all women diagnosed with breast cancer are treated. The discovery of an overdiagnosed cancer, therefore, can result in overtreatment, including invasive procedures, chemotherapy, and radiation, that can have significant harms. It’s important for all women to have all the available evidence so they can have a conversation with their doctors about the potential benefits and harms of screening and make the decision that is best for them.

Is there a concern that these guidelines may add to the confusion that already exists regarding the optimal frequency of breast cancer screening?

The Task Force’s findings affirm a convergence among groups who have recently issued evidence-based guidelines. The Task Force, the American Cancer Society, and many others have affirmed that mammography is an important tool to reduce breast cancer mortality and that the benefits of mammography increase with age. Support of a personal, informed choice for women in their early 40s is shared by the Task Force, the American Cancer Society, the American College of Physicians, the American Academy of Family Physicians, and the Canadian Task Force on Preventive Health Care. The Task Force and others fully support the shift toward shared decision making that is emerging, and we are glad to see that it is part of a larger movement toward empowering people with information not only about the potential benefits but also the potential harms of screening tests. The Task Force is hopeful that our recommendations on breast cancer screening will be perceived as an important part of a growing consensus among experts in evidence-based medicine.

The Task Force addresses the insurance issue regarding screening. Is there a concern that women may be refused screening based on these new guidelines?

The Task Force does not make recommendations for or against insurance coverage and its final recommendations do not impact insurance coverage for breast cancer screening. Through a unique provision of federal law, legislators guaranteed that women in their 40s, as well as older women, who have private insurance will not have a co-pay for their screening mammogram. Coverage of mammography for Medicare beneficiaries was established by another statute and is not bound by Task Force recommendations. As clinicians, we hope that our nation will continue to strive to help all individuals get access to those preventive services that can enable people to live healthier, longer lives.

What is the take-away message from the guidelines?

We believe all women deserve to understand what the science says about both the potential benefits and harms of breast cancer screening-so they are empowered to make the best choice for themselves, together with their doctor. We hope our work can help advance progress in that direction for the benefit of all women. The science shows that screening is most beneficial for women ages 50 to 74. For women in their 40s, our findings support a range of individual choices-from beginning regular mammograms sometime during this decade, to waiting until age 50 to begin screening.​