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NEWS & VIEWS |
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Although the American Cancer Society (ACS) and the United States Preventive Services Task Force recommend that women in their 40s get regular mammograms, the American College of Physicians (ACP) recently issued different advice.
In April, the ACP published clinical practice guidelines saying women in their 40s should talk with their doctors about their individual risk for breast cancer and the benefits and harms of mammography before deciding whether to get screened before age 50.
"There are important benefits to screening mammography, but we believe the decision to be screened should be based on an informed conversation between a patient and her physician," Douglas K. Owens, MD, MS, Chair of the committee that developed the guidelines, said in a statement. Owens is a Professor of Medicine at Stanford University School of Medicine. "In our view, the evidence doesn't support a blanket recommendation for women in this age group."
The ACS's Director of Cancer Screening, Robert Smith, PhD, said talking with a doctor about the benefits and limitations of mammography makes sense for all women over the age of 40, but there's plenty of evidence to recommend mammography for women in that age group.
"The American Cancer Society and other organizations have endorsed mammography screening for women in their 40s because direct and inferential evidence supports its value in reducing morbidity and mortality from breast cancer, the second leading cause of cancer death in women," he said.
Other groups that recommend mammograms every 1 or 2 years for women in their 40s include the United States Preventive Services Task Force and the American College of Obstetricians and Gynecologists.
Breast cancer is the most common cancer among women (other than nonmelanoma skin cancer), and about 17% of invasive breast cancers occur in women in their 40s. The ACS estimates that 178,480 women will be diagnosed with invasive breast cancer in 2007, and 40,460 will die from it.
The ACP guideline is not based on any new study, but rather cites a recent meta-analysis of the randomized clinical trials that showed mammograms can reduce breast cancer deaths by about 15% among women in their 40s. But Smith says more recent trials and evaluations of population-based screening programs indicate the reduction is much greater—40% or more.
The ACP guideline was published in the Annals of Internal Medicine (2007;146:511–515). It emphasizes discussing a woman's individual risk of breast cancer when deciding whether she should get screened. But predicting breast cancer risk for any one woman is inherently inaccurate; an editorial published along with the new guidelines acknowledges that such predictions are "extremely inexact."
"While such factors as family history of breast cancer, breast density, and genetic mutations may help identify women at increased risk, most women with diagnosed breast cancer have none of these risk factors," wrote University of Washington editorialists Joann Elmore, MD, MPH, and John Choe, MD, MPH.
That fact is key, said Smith.
"If we were to screen only those women in their 40s who had significant, known risk factors, we would fail to detect the majority of breast cancers that arise during that decade of life," he pointed out.
The ACP guideline also says doctors should discuss with women the "benefits and potential harms" of mammography.
The most important benefit, of course, is the drop in breast cancer deaths. The potential harms include pain from the procedure, radiation exposure, and the anxiety and fear that can result from false-positive findings. Smith, however, said that surveys of women confirm that most are willing to accept false positives because of the substantial net benefits of mammography.
Guideline Committee Chair Owens acknowledged that the benefit of mammograms will probably outweigh other concerns for most women in their 40s.
"We still think many women will choose to get mammography, and we're supportive of that," he said. "The most important thing is that women be well informed about the decision they're making."
Smith agreed that women should be given the facts about mammography.
"All organizations endorse giving women the facts about mammography, that it has benefits, limitations, and that false-positive results are common over a lifetime of screening," he said.
But he worries that the ACP guidelines will cause some women to skip mammograms.
"The new ACP guideline represents a step backward because it departs from the consensus in screening recommendations that has evolved through years of careful evaluations of all the scientific evidence," Smith said. "It would be a major public health setback if these new guidelines caused some women and their doctors to conclude that screening can safely be postponed."
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