It’s not a matter of if … but when and how often.

It would be difficult to find a women’s health expert who questioned the life-saving potential of early detection and treatment of breast cancer. In fact, statistics show death rates from breast cancer have steadily declined over the last two decades as screening tools and treatment protocols have become more sophisticated and effective. Instead, the controversy stems from pinpointing the optimal time for women to begin having mammograms and the frequency of routine screenings thereafter in an age of soaring healthcare costs and national debt crisis.

The National Quality Measures Clearinghouse, an agency of the U.S. Department of Health and Human Services, has shown a reduction in death rates of 20-30 percent among women 40 or older through the use of mammography. However, research also shows breast cancer incidence and death rates generally increase with age. In fact, the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute found that between 2004-2008, the median age at diagnosis for breast cancer was 61 years.

While mammograms have played an essential role in the early detection of breast cancer, the screening tool also turns up false positive results, requiring additional pictures or studies such as ultrasound, MRI or image-guided biopsy. Proponents of a delayed or less frequent screening schedule find the associated cost and anxiety, coupled with low incidence rates among younger women, offset the need to begin routine screenings at 40 unless other risk factors exist such as a familial history of breast cancer.

The controversy over timing and frequency reached fever pitch in November 2009 when the United States Prevention Services Task Force (USPSTF) released new recommendations for mammography screening. Prior to that time, the widely accepted standards called for a baseline mammogram at some point between the ages of 35 and 40 with annual screenings for all women age 40 and up. The USPSTF report considerably changed that schedule by recommending against routine screenings for women in their 40s, mammograms every two years from age 50-74, and no routine screening at all for women ages 75 and up.

The debate raged on last month as a new study out of the California Pacific Medical Center Research Institute — part of Sutter Health network — and updated recommendations from the American College of Obstetricians and Gynecologists (ACOG) were released within three weeks of each other. ACOG revised their recommendations to match those of the American Cancer Society, Society of Breast Imaging and American Society of Breast Disease to call for more frequent screenings beginning at 40, while the California study called for an end to ‘one size fits all’ guidelines based on age.

Prior to July 2011, ACOG recommended mammograms every one-to-two years starting at age 40 and annually beginning at 50. The revised guidelines call for annual screening to be offered to all women beginning at age 40. Thomas J. Herzog, MD, FACOG, who chairs ACOG’s Gynecologic Oncology subcommittee, said the update was to keep up with the current literature and research. “The last update was in 2003 so it has been a significant amount of time.” The director of Gynecologic Oncology at New York-Presbyterian Hospital/Columbia University Medical Center ruefully noted the ensuing years have seen a tremendous amount of controversy on the subject.

Herzog said the cost effectiveness of routine mammography is pretty clear in the 50s, 60s, and 70s. “The challenge becomes the 40s because the chances of developing cancer are low … like 1 percent … so it pushes the cost curve. That’s where other groups have challenged whether it makes sense to do the routine screening in women between the ages of 40 and 50.” In that gray area, he noted, ACOG has decided to lean toward ‘help not harm.’ Herzog added his personal opinion, “I think, when uncertain, it makes more sense to err on the side of protecting your patients.”

One cause for caution is the sojourn time for breast cancer growth from the point where it might be detected by a mammogram to when it is large enough to become symptomatic. While sojourn times vary, age is a key predictor. On average, women 40-49 have the shortest sojourn time (2-2.4 years); whereas women ages 70-74 typically have double that (4-4.1 years). The five-year survival rate for women whose breast cancer tumors are discovered at their earliest stage … before they are palpable and when they are small and confined to the breast … is 98 percent.

“We’ve seen significant stage migration in the sense that more of these patients are picked up at an earlier stage,” Herzog said, adding this “allows for less radical treatment and confers better prognosis.”

These parameters played into ACOG’s decision to recommend annual mammograms beginning at 40 and to continue with a clinical breast exam (CBE) annually for all women ages 40 and up and a CBE once every one-to-three years for women 20-39.

However, Herzog said the screening issue cannot be looked at in a vacuum. He added that with today’s fiscal realities and limited budget for screenings, “We need to be mindful of how we most effectively spend this money.” He added that the reality is that a smaller group probably needs intensive screenings and that a large portion of the population would probably be fine with screenings every two or three years. He was quick to add, although, that the science isn’t there yet and would require more research to determine which women fall into what group. “Although we’d have to invest to develop that knowledge base, it would save us hundreds of thousands of dollars in screening annually.”

Conversely, Steve Cummings, MD, director of the San Francisco Coordinating Center at California Pacific Medical Center Research Institute who headed up the frequency study project that appeared in the July 5 issue of the Annals of Internal Medicine, said factors do exist to determine how often a woman should have a mammogram and that the answer isn’t going to be the same for every woman or every age group.

“This is the first analysis to totally take account of a woman’s risk in deciding how frequently to have a mammogram,” Cummings stated. “We recommend a woman should have a mammogram at age 40 … not because that’s when a woman should be screening but because that’s when she should have an assessment of her risk of breast cancer.”

He noted, “Most guidelines use age as the determining factor in when, and how often, a woman should get a mammogram. What our study shows is that the other factors, particularly breast density, are just as important, if not more so, in helping a woman decide what is most appropriate for her. We show that mammography should be personalized.”

The researchers, who used SEER data, developed a model to compare the lifetime costs and health benefits for women who got mammograms every year, every two years, every three-to-four years or never. The analysis suggested the three most important risk factors are family history, having had a breast biopsy in the past, and breast density. “In particular, knowing your breast density is far more useful than any other test you can get,” he said of deciding on an individual screening schedule. “Breasts that have more tissue are more likely to give rise to cancer,” Cummings said, adding that radiologists can rate a woman’s breast density from 1-4 with 4 being the highest density.

“For women age 40-49 with high breast density and with either a first-degree relative with breast cancer or a prior breast biopsy, the benefits versus harm for performing mammography every two years is similar to screening an average-risk woman in her 50s,” explained study co-author Karla Kerlikowske, MD, MS. “This amounts to about 20 percent of women in their 40s,” she continued. “For women age 40-49 without these risk factors, it is reasonable to wait until age 50 to start mammography screening.”

Also of importance are a woman’s personal beliefs and ‘scare’ threshold. “None of the analysis that have been published up until now really take account of a woman’s preference,” said Cummings. “Quality of life matters as much as quantity.” He went on to say that if mammograms are reassuring to a woman, then that adds to her life. If, on the other hand, a false positive causes undue anxiety, then less frequent mammograms might be the answer. 

By 50, Cummings said all women should start screening. “Fifty is a good time to figure out how frequently they should have mammograms after that.” He added, those with low density breasts still might only screen every three or four years, depending on their preference. “That’s radically different from other guidelines,” he noted.

Although recognizing this latest opinion on timing and frequency will likely only add to the general controversy surrounding mammography screenings, Cummings said he is confident this approach will ultimately be the most recognized. “It allows women and their doctors to personalize and to have a lot of choice, and I think that’s the way it ought to be,” he concluded.

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