Making Sense Out of the New Breast Cancer Screening Guidelines

In November 2009, an updated recommendation by the U.S. Preventive Services Taskforce (USPSTF) on screening for breast cancer was published in the Annals of Internal Medicine. The updated recommendation, which was written to help guide health care providers, differs from prior recommendations in several ways, including these:

• Prior recommendation: Routine mammograms every 1-2 years for women 40 years and older
• New recommendation: Age 40-49: Consider mammograms every 2 years on an individual basis, taking into account patient values and risk factors, but don’t just do it routinely for everyone. Age 50-74: Routine mammograms every 2 years.  Age 75 and over: Whether or not mammograms are helpful is unknown

These new recommendations have made quite a stir, and led to more than a little confusion among patients as well as health care providers. So how do we make sense out of a group like the USPSTF, which I have found to be more objective and thorough than most, making such recommendations like these that not everyone agrees with?

First, it is important to understand that there is no absolute right or wrong here; it is a matter of balancing the possible benefits and harms, and making a judgment. For example, I do not think anyone reading this would recommend that all women have mammograms every month starting at age 21. But why not? Wouldn’t it save more lives from breast cancer, compared to screening less often or waiting until age 40 or 50? Of course it would. But the cost of doing monthly mammograms at these young ages would be relatively high in terms of radiation exposure, biopsies for false positive tests, and money, and the benefit would be relatively small because breast cancer is very rare at younger ages.

So where do you draw the line? When should we health care providers start recommending that women have mammograms? Again, there is no right or wrong answer to this, and professional organizations have different ways of deciding what they are going to recommend. I would say that talking about it with our female patients age 40-49, rather than routinely recommending it, is a rational approach based on good research. It also involves some degree of judgment, and therefore is a position that reasonable people could reasonably disagree on.

Finally, this guideline, like all guidelines, can and should be used thoughtfully and skillfully by primary care providers in consideration of their patients’ needs and preferences. Remember, guidelines are written for populations, but applied to individuals.