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New recommendations on screening for breast cancer in the USA recently presented by the US Preventive Services Task Force (USPSTF) and the Society of Breast Imaging and American Council of Radiologists (ACR) provoke some concerns about the optimal screening strategy for breast cancer. USPSTF recommendations published in November 2009 do not recommend screening mammography in women younger than 50 years old because of high false-positive rates and low effects on mortality and vote against self examination of the breast because of lacking evidence for survival benefit from randomized trials. Nevertheless, the ACR guidelines published two months later strongly support the beginning of screening mammography by the age of 40.
We asked Dr. Kettritz whether the new recommendation from the USA might have impact on the clinical routine in Europe?
Oleg Gluz and Cornelia Liedtke
U.S. Preventive Services Task Force, Agency for Healthcare Research and Quality: Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2009; 151:716–726.
Description: Update of the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for breast cancer in the general population. Methods: The USPSTF examined the evidence on the efficacy of 5 screening modalities in reducing mortality from breast cancer: film mammography, clinical breast examination, breast self-examination, digital mammography, and magnetic resonance imaging in order to update the 2002 recommendation. To accomplish this update, the USPSTF commissioned 2 studies: 1) a targeted systematic evidence review of 6 selected questions relating to benefits and harms of screening, and 2) a decision analysis that used population modeling techniques to compare the expected health outcomes and resource requirements of starting and ending mammography screening at different ages and using annual versus biennial screening intervals. Recommendations: The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient's values regarding specific benefits and harms. (Grade C recommendation). The USPSTF recommends biennial screening mammography for women between the ages of 50 and 74 years. (Grade B recommendation). The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (I statement). The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women 40 years or older. (I statement). The USPSTF recommends against clinicians teaching women how to perform breast self-examination. (Grade D recommendation). The USPSTF concludes that the current evidence is insufficient to assess additional benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities for breast cancer. (I statement).
Lee CH, Dershaw DD, Kopans D, Evans P, Monsees B, Monticciolo D, Brenner RJ, Bassett L, Berg W, Feig S, Hendrick E, Mendelson E, D'Orsi C, Sickles E, Burhenne LW: Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol 2010;7:18–27.
Screening for breast cancer with mammography has been shown to decrease mortality from breast cancer, and mammography is the mainstay of screening for clinically occult disease. Mammography, however, has well-recognized limitations, and recently, other imaging including ultrasound and magnetic resonance imaging have been used as adjunctive screening tools, mainly for women who may be at increased risk for the development of breast cancer. The Society of Breast Imaging and the Breast Imaging Commission of the ACR are issuing these recommendations to provide guidance to patients and clinicians on the use of imaging to screen for breast cancer. Wherever possible, the recommendations are based on available evidence. Where evidence is lacking, the recommendations are based on consensus opinions of the fellows and executive committee of the Society of Breast Imaging and the members of the Breast Imaging Commission of the ACR.
Despite the same goal, namely detecting early breast cancer in asymptomatic women, modalities of performing breast cancer screening vary. In Europe, most countries including Germany follow the European Guidelines to offer mammography biennially in women 50–69 years, although there are some programs that include age groups 40–49 years and women older than 69 years. While significant mortality reduction within the age group 50–69 is widely accepted, there is still a controversial discussion about the screening benefit for women 40–49 years.
In the US, until November 2009 recommendations issued by the U.S. Preventive Services Task Force (USPSTF), the American Cancer Society, the National Comprehensive Cancer Network and the American College of Radiology (ACR) were valid, recommending annual mammography starting at the age of 40 years. In November 2009, a heated debate on the age of the target population and the screening interval started with the revised USPSTF recommendation statement, published in Annals of Internal Medicine under the category ‘Clinical Guidelines’. The USPSTF updated their 2002 recommendations for mammography screening, now recommending biennial versus annual screening for women between 50 and 74 years. Furthermore, the authorities suggested that screening ends at the age of 74 years, and recommends that no routine screening mammography should be performed in women aged 40–49 years. Based on a systematic review of the evidence of benefits and harms, they concluded that in women 40–49 years old, the balance between harm, such as false positive results, and benefit in terms of mortality reduction is not sufficient to recommend regular mammography in asymptomatic, non high-risk women in this age group.
The answer appeared instantly. Carol H. Lee, chair of the ACR Breast Imaging Commission, voted in January 2010 for the ACR to hold onto the earlier recommendations. The ACR again recommend screening annually beginning at age 40. In contrast to the USPSTF, the ACR recognized the benefits of digital mammography for women with denser breasts and encouraged radiologists to use this method.
Even considering responses that arose from many non-US countries, this debate seems to be rather US-specific. In contrast to discussions in Europe, it is interesting to notice that the need to consider the disadvantages of screening mammography, such as radiation exposure and a higher incidence of false positive findings is less emphasized. Under the conditions of the health insurance system in the US, breast imaging specialists are afraid that these new recommendations are a first step towards imperfect health service, even for women with risk factors.