Why Mammogram Screening Guidelines Have Changed and What I Think

Not all organizations agree on mammogram guidelines. For instance, the U.S. Preventive Services Task Force mammogram guidelines recommend women begin screening at age 50. The American Cancer Society, the National Comprehensive Cancer Network and other organizations recommend that women begin screening in their 40s. Some organizations recommend screening every year and others recommend screening every two years.

For years the American Cancer Society (ACS) has recommended women should get annual mammograms starting at age 40. Now it says they can start at 45 — and then cut back to every other year starting at age 54.

It seems to me the ACS is saying while there are benefits to screening, particularly in younger women, there can also be downsides – some of which are pertinent to radiology (additional mammograms, ultrasounds, MRIs, etc..) and some of those are related to pathology (getting biopsies).

And this is where I think we are learning the problems can really start – you may have an “atypical” mammogram with an “atypical” biopsy (and well known inter-observability here in pathology and presume some level as well in radiology). Atypical biopsies may lead to additional surgery, radiation and chemotherapy. These could range from wire-localization biopsies to lumpectomies or perhaps even mastectomies.

I think this problem started after last week around 2009 when the U.S. Preventive Services Task Force that really opened up this can of worms. It announced that it was recommending that women wait even longer until they’re 50 before they start screening and then get a mammogram every other year and ever since then there’s been intense debate about what’s the right thing to do when it comes to mammograms.

The advice here seems to be that it’s better not knowing what kind of minor ailments or potential ailments or false alarms you might have. And based on numerous studies measured with cost of screening, biopsies, procedures, treatments and follow-up necessary the ACS has seemed to conclude the risk:benefit ratio justifies beginning screening at a later age and even malignancies detected then can be treated with similar outcomes than with earlier screening.

Perhaps we have learned so much about the biology of breast cancer that these recommendations are justified for waiting to be screened. And then screened less frequently.

Where have we seen this before?

The pap smear.

The most effective cancer screening test ever developed has seen its effectiveness in terms of public health diminished with the use of HPV testing (the virus that causes cervical carcinoma and accounts for the morphologic changes in pre-neoplasia), vaccines and longer interval screening.

I think as healthcare begins to look at population-based care in the era of “personalized” care we are making more generalizations rather than “personalizations”.

And I think this is bad for everyone.