Last week, the American Cancer Society—one of the leading cancer non-profits in the United States—updated their guidelines to recommend women begin receiving mammograms at age 45 instead of age 40.
As a longtime breast surgeon and the founder of The Maurer Foundation, an organization dedicated to education on the importance of early detection and prevention of breast cancer, I am disappointed and surprised by these new guidelines.
I share the concerns of many of my colleagues, including the National Comprehensive Cancer Network and the American College of Obstetricians and Gynecologists, about the new guidelines and continue to recommend women begin mammograms at age 40.
There are a few reasons why I disagree with the American Cancer Society’s new guidelines:
The research is not based on the most current and effective forms of mammography.
Practically speaking, although the studies referenced in creating the new guidelines were all published after 2000, major advancements have been made in mammography in the past 15 years—meaning some of the data these new guidelines are based upon are already outdated. For instance, many of the studies were primarily based on film mammography, which detects fewer cancers and results in more false positives than digital mammography and 3D tomosynthesis. New 3D tomosynthesis mammography is also more effective at detecting cancer in women with dense breast tissue—which, commonly, includes women under 45. Focusing on the future of mammography, rather than its past, could result in significantly different outcomes and recommendations.
The research is not representative of all populations, and could potentially harm minorities at high risk.
As Linda Blount, president of the Black Women’s Health Imperative and a former executive at the American Cancer Society, writes in an NBC News editorial, the guidelines also may have unintended impacts on minorities. Blount is concerned that the guidelines are based primarily on studies of white women, and do not account for statistics reflecting that black women are diagnosed with breast cancer younger than 45 and die more frequently from it than white women.
The guidelines are based on the premise that the negative effects of false positives outweigh the life-saving outcome of early cancer detection.
Finally, the guidelines are based on the premise that the benefit of mammograms for women under 45—that is, the benefit of detecting breast cancer earlier—is outweighed by the harm of false positives and unnecessary procedures.
We should be clear that this is not a conversation about overdiagnosis, which is the clinical term for detecting a cancer that actually does not require treatment and then pursuing unnecessary chemotherapy or surgery. The editorial accompanying the American Cancer Society guideline update clearly states “Uncertainty about overdiagnosis seriously limits understanding of whether the potential benefits of annual mammography among younger women outweigh the risks”; and the study including the guidelines acknowledges that the “quality of the evidence for overdiagnosis is not sufficient” to make a recommendation.
So the risk being discussed here is not the risk of unnecessary chemotherapy or breast surgery, but the risk of false positives. A false positive occurs when a woman has a mammogram, and is called back for further screening, potentially including a biopsy. Further screening reveals that cancer is not present, but the woman has had to undergo procedures and stress that she would have avoided had she not had a mammogram. The data cited by the American Cancer Society suggests that a woman beginning mammograms at age 40 has a 50-50 chance over her lifetime of experiencing a false positive result.
In my professional opinion, that risk does not outweigh the benefit of mammograms for women between 40-45 years old—especially if we consider the rate of false positives is about 15% lower when 3D tomosynthesis is used. Approximately 26,000 women under the age of 45 are diagnosed with breast cancer each year, and mammograms simply provide the best method of detecting those cancers early and increasing the survival rates of those women.
These mixed messages and conflicting guidelines could result in one grievous outcome: women feel uninformed and powerless when it comes to their breast health. We have built The Maurer Foundation to empower women, and I continue to encourage every woman to be her own best advocate. Educate yourself on your risk factors and family history, ask questions when you visit your doctor, and ask for a mammogram beginning at age 40 if you believe the risk of a false positive is worth the possible benefit of detecting cancer early.
