Among other recommendations, new breast cancer screening guidelines from the American Society of Breast Surgeons (ASBrS) say:
- All women age 25 and older should have a formal risk assessment for breast cancer.
- Women with an average risk of breast cancer should start annual screening mammograms at age 40.
- Women with a higher-than-average risk of breast cancer should start annual screening mammograms at an earlier age and should be offered additional imaging each year.
The guidelines were announced on May 3, 2019, at the group’s annual meeting in Dallas. Read the American Society of Breast Surgeons Position Statement on Screening Mammography.” (PDF)
The mammogram debate
The new ASBrS screening guidelines differ from guidelines from the U.S. Preventive Services Task Force (USPSTF), which recommends that mammograms start at age 50, and the American Cancer Society, which recommends that mammograms start at age 45, and will likely stir up the debate about when mammograms should start and who should have a mammogram.
Several large studies, including a review by the USPSTF in 2009 and a study on the causes of death in the United Kingdom in 2013, have questioned the value of screening mammograms.
Doctors who question the value of mammograms say that while mammograms do save lives, for each breast cancer death prevented, three to four women are overdiagnosed. Overdiagnosis means either:
- a screening mammogram finds a suspicious area that would have been eventually diagnosed as cancer by other means, without any effect on prognosis
- a screening mammogram finds a suspicious area that never would have affected a woman’s health if it hadn’t been found or treated
False-positive results from screening mammograms also have helped fuel the debate about the value of breast cancer screening. When a mammogram shows an abnormal area that looks like a cancer but turns out to be normal, it’s called a false positive. Ultimately the news is good: no breast cancer. But the suspicious area usually requires follow-up with more than one doctor, extra tests, and extra procedures, including a possible biopsy. There are psychological, physical, and economic costs that come with a false positive.
Since 2013, the American Medical Association, the American College of Obstetricians and Gynecologists, the American College of Radiology, the National Cancer Institute, and the National Comprehensive Cancer Network all have issued guidelines saying that all women should be eligible for screening mammograms starting at age 40.
"Initiating screening mammography at age 40 undoubtedly saves more lives through early detection of disease compared to alternative schedules, and was therefore the 'traditional' age recommended in clinical practice until approximately 10 years ago, when the USPSTF published a revised guideline," Lisa Newman, M.D., chief of breast surgery at New York-Presbyterian/Weill Cornell Medicine in New York City, said in an interview. Newman was one of the authors of the new ASBrS guidelines.
"The ASBrS position statement advocates for annual screening mammography beginning at age 40 years, because we have chosen to prioritize the life-saving benefits of screening mammography," Newman added. "Furthermore, as physicians that guide patients through decisions regarding management of breast cancer on a daily basis, we have unique perspectives regarding the value of early detection and its impact on surgical as well as systemic and radio-therapeutic options."
The ASBrS guidelines recommend:
- All women should have a formal breast cancer risk assessment done by their doctors between age 25 and 30. This assessment should be updated at regular intervals.
- All women should have screening with 3D mammograms (also called digital breast tomosynthesis, digital tomosynthesis, or just tomosynthesis), which create a 3D picture of the breast using X-rays. Several low-dose images from different angles around the breast are used to create the 3D picture.
- Women at average risk of breast cancer should receive annual screening mammograms starting at age 40. Women at average risk with dense breasts should consider supplemental imaging.
- Women with a higher-than-average risk of breast cancer because of a known genetic mutation or radiation to the chest wall earlier in life should receive an annual screening MRI starting at age 25 and annual screening mammograms starting at age 30.
- Women with a higher-than-average risk of breast cancer because of a strong family history of breast cancer or who have a lifetime risk of breast cancer that is greater than 20% as calculated by a standard risk model should receive an annual screening mammogram starting at age 35 and supplemental imaging as recommended by their doctors.
- Women age 50 or older with a history of breast cancer who have non-dense breasts should have a mammogram every year.
- Women younger than 50 with a history of breast cancer, or who have dense breasts, should have a mammogram every year and supplemental imaging as recommended by their doctors.
- Women should continue having annual mammograms until their life expectancy is less than 10 years.
"At this point in time we have the most robust data regarding breast cancer risk and screening benefits among women with pathogenic mutations in the BRCA1 and BRCA2 genes," Newman said. "History of therapeutic chest wall radiation during adolescence/early adulthood and women with strong family histories of early onset breast cancer — even if a pathogenic mutation has not been identified in the family — represent other examples where mammographic screening at younger ages, as well as supplemental screening with breast MRI, should be considered."
What this means for you
At Breastcancer.org, we believe that a woman’s best chance for early detection requires coordination of our current screening tools:
- high-quality mammography
- clinical breast exam
- breast self-exam
To not use all three tools in women ages 40 to 45 and to do mammograms alone (without clinical or self-exam) in women older than 45 are missed opportunities for early detection.
The reality is that every woman is at risk for breast cancer, and this risk tends to increase over time. It’s important to understand and regularly update your health information related to breast cancer risk throughout your life with your doctor. To get the conversation started, here are some points to talk to your doctor about:
- family history of breast or other related cancers (ovarian, melanoma)
- any test results for abnormal genes linked to a high risk of breast cancer
- results of past breast biopsies, even if they were benign
- personal history of being treated with radiation to the face and/or chest before age 30
- breast density
- weight, if you’re overweight or obese
- level of physical activity
- any use of postmenopausal combined hormone replacement therapy (HRT)
- alcohol consumption, if you regularly drink more than 3 alcoholic beverages per week
- the amount of processed food and trans fats you eat
- your smoking history
- whether or not you had a full-term pregnancy or breastfed
Breastcancer.org recommends that women at average risk of breast cancer have mammograms annually starting at age 40, and we are pleased to see this in the new ASBrS guidelines. We also believe that monthly breast self-exam and annual physical exams by a doctor are essential parts of an overall breast cancer screening strategy.
If you’re at high risk for breast cancer, you should talk to your doctor about starting annual mammograms at a younger age and consider other screening tools (such as MRI or ultrasound) to maximize the opportunity for early detection.
For more information on the tests and tools used to screen for breast cancer, visit the Breastcancer.org Screening and Testing pages.
Written by: Jamie DePolo, senior editor
Reviewed by: Brian Wojciechowski, M.D., medical adviser
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