New mammography guidance throws another twist into screening debate
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New guidelines changing the recommended screening age for breast cancer to 40 years old from 50 are adding another wrinkle to the confusing discussion over when and how often to get mammograms.
Driving the news: The draft guidance the U.S. Preventive Services Task Force released on Tuesday for women with average risk estimated that starting screenings a decade earlier could save 19% more lives.
- But they marked a reversal from 2009 guidance that raised the minimum recommended screening age.
- The latest revision, which recommends biannual screenings, also is in conflict with yearly screening recommendations supported by leading medical organizations such as the American College of Radiology, the American Society of Breast Surgeons and the American Cancer Society.
What they are saying: "It's confusing for physicians and providers who are then counseling patients," Vivian Bea, section chief of breast surgical oncology at NewYork-Presbyterian Brooklyn Methodist Hospital and a breast surgeon at Weill Cornell Medicine, told USA Today, calling for unified guidance. "It's also confusing for patients."
The big picture: The differing recommendations put a burden on clinicians trying to deliver a clean takeaway for sometimes overwhelmed patients.
- A 2022 KFF survey found 24% of women between the ages 50 and 64 have not had a mammogram in the last two years and 28% of those said they didn’t think it was needed.
- The task force guidance may help clarify the fact women of average risk should be getting this screening starting at 40, which many were already doing, said William Dahut, chief scientific officer for the American Cancer Society.
- But "there will still be a lot of questions about newer technologies and supplemental screening on top of that," he said. "For higher risk populations, 'Should they be screened at even earlier ages?'"
Be smart: This change should not impact insurer coverage, Ivette Gomez, policy analyst for KFF’s women’s health policy team told Axios.
- Remember, a U.S. federal judge ruled in March that employers can’t be required to cover specific preventative health care services under the Affordable Care Act in a case that directly impacted USPSTF recommendations.
- In this case, ACA rules require insurers to follow the guidance of a different medical body, the HRSA-sponsored Women’s Preventive Services Initiative (WPSI) to make coverage decisions, she said.
- WPSI recommends average-risk women initiate mammography no earlier than 40 and no later than 50.
Between the lines: Among the lingering questions is what's appropriate for women with dense breasts who are at higher risk for breast cancer and for whom mammography is less effective.
- Then, there are questions about the technology that's available. The task force didn't take a clear stance on whether women should be seeking innovations like 3D mammography that are widely touted by health systems, and whether it offers an advantage over more conventional screening. Nor was there clear guidance on the value of seeking adjunct testing such as genetic screening or MRI screening," Jessica Paulus, vice president of research for medical research data company OM1, told Axios.
- A major clinical trial known as the TMIST study may settle that debate, but is not expected to yield results until at least 2030, Paulus pointed out.
- "There are people like me who are doing real-world-based observational studies trying to address some of these questions," she said. "The quality of that evidence is potentially less than that randomized trial but these questions are so important that we don't want to wait until 2030 to wait for the perfect evidence."
Zoom in: The guidance did draw attention to racial and ethnic disparities in breast cancer outcomes and the need for research.
- For instance: "Research is needed to understand the underlying causes of the increased risk of breast cancer mortality in Black women, across the spectrum of stages and biomarker patterns," they wrote.
- For some subgroups of women with higher risk of breast cancer and breast cancer death, more intensive screening may be worth the risks of increased chances of false positives, the USPSTF said, but concluded the current evidence is inconclusive.
But, Paulus said, it's not clear how treatments are going to change, especially for women with a low risk of developing cancer who may be cost-sensitive and wary of the potential risk of false positives, and the need for more testing or biopsies. "With that cost-benefit analysis for younger women, I didn't see that completely handled here," Paulus said.
