Breast Cancer

When the American Cancer Society (ACS) updated its guidelines for screening mammography earlier this week,¹ the effect was that of a stone being tossed into a tranquil pond, generating ripples in all directions.

The new guidelines focus on women at average risk for breast cancer (TABLE 1) and were updated for the first time since 2003, based on new evidence, a new emphasis on eliminating as many screening harms as possible, and a goal of “supporting the interplay among values, preferences, informed decision making, and recommendations.”¹ Earlier ACS guidelines recommended annual screening starting at age 40.
 

The new guidelines are graded according to the strength of the rec ommendation as being either “strong” or “qualified.” The ACS defines a “strong” recommendation as one that most individuals should follow. “Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator,” the guidelines note.¹

A “qualified” recommendation indicates that “Clinicians should acknowledge that different choices will be appropriate for different patients and that clinicians must help each patient arrive at a management decision consistent with her or his values and preferences.”¹

The recommendations are:

ACOG weighs in
Shortly after publication of the new ACS guidelines, the American College of Obstetricians and Gynecologists (ACOG) issued a formal statement in response²:

Response of the USPSTF
The US Preventive Services Task Force (USPSTF) also issued a statement in response to the new ACS guidelines:

The USPSTF currently recommends biennial screening beginning at age 50.

A leader in breast health cites pros and cons of ACS recommendations
Mark Pearlman, MD, professor of obstetrics and gynecology at the University of Michigan health system, is a nationally recognized expert on breast cancer screening. He sits on the National Comprehensive Cancer Network (NCCN) breast cancer screening and diagnosis group, helped author ACOG guidelines on mammography screening, and serves as a Contributing Editor to OBG Management.

“I believe the overall ACS mammography benefit evidence synthesis is reasonable and is in keeping with both NCCN and ACOG’s current recommendations. NCCN and ACOG mammography screening recommendations have both valued lives saved more highly than the ‘harms’ such as recalls and needle biopsies,” Dr. Pearlman says.

“If one combines ACS ‘strong’ and ‘qualified’ recommendations, ACS recommendations are similar to current ACOG and NCCN recommendations for mammography,” he adds.

Dr. Pearlman finds 7 areas of agreement between NCCN/ACOG and ACS recommendations, using both strong and qualified recommendations:

Where the ACS and ACOG/NCCN disagree is over the issue of the physical exam (abandoning CBE in average-risk women).

In regard to this last item, Dr. Pearlman says, “The ACS made a qualified recommendation against clinical breast exam. There is no high-level data to support such a marked change in practice. For example, when recommendations against breast self-examinations (BSE) were made, there were randomized controlled trials (RCTs) showing a lack of benefit and significant harms with BSE. With RCT-level data, it made sense to make a recommendation against the long-taught practice of SBE in average-risk women. That was not the case here. In fact, there are small amounts of data showing benefits of clinical breast exam.”

“One of my biggest concerns is not just the recommendation against CBE,” says Dr. Pearlman, “but that this may lead many women to interpret [this statement] as if they do not need to see their health care provider anymore. As you may recall, the American College of Physicians (ACP) recommended against annual pelvic examinations in asymptomatic patients. The ACS recommendation statement—taken together with the ACP statement—basically suggests that average-risk women don’t ever need to see a provider for a pelvic or breast examination except every 5 years for a Pap smear. That thinking does not recognize the importance of the clinical encounter (not just the CBE or pelvic exam), which is the opportunity to perform risk assessment and provide risk-reduction recommendations and healthy lifestyle recommendations.”

Radiologists resist new recommendations
Although the American College of Radiology (ACR) and the Society of Breast Imaging (SBI) agree with the ACS that mammography screening saves lives and should be available to women aged 40 and older, the 2 imaging organizations continue to recommend that annual screening begin at age 40. Their rationale: The latest ACS breast cancer screening guidelines, and earlier data used by the USPSTF to create its recommendations, both note that starting annual mammography at age 40 “saves the most lives.”

Where the organizations differ from the ACR is summed up by a formal statement on the ACR Web site: “The ACR and SBI strongly encourage women to obtain the maximum lifesaving benefits from mammography by continuing to get annual screening.”⁴

When OBG Management touched base with radiologist Barbara Monsees, MD, professor of radiology and Evens Professor of Women’s Health at Washington University Medical Center in St. Louis, Missouri, she expressed dismay at early news reports on the ACS guidelines.

“I’m dismayed that the headlines don’t seem to correlate with what the ACS actually recommended. The ACS did not state that women should wait until age 45 to begin screening. I believe the ACS was going for a more nuanced approach, but since that’s a bit complicated, I think that reporters have misconstrued what was intended,” Dr. Monsees says.

“The ACS guideline says that women between 40 and 44 years should have the opportunity to begin annual screening,” she says, noting that this recommendation was graded as “qualified.”

“The ACS states that a qualified recommendation indicates that ‘there is clear evidence of benefit of screening, but less certainty about the balance of benefits and harms, or about patients’ values and preferences, which could lead to different decisions about screening.’” The guideline also articulates the view “that the meaning of a qualified recommendation for patients is that the ‘majority of individuals in this situation would want the suggested course of action, but many would not.’ Therefore, I find it mind-boggling that this has been interpreted to mean that women should not begin screening until age 45.”¹

“It is my opinion that it is clear that if women want to achieve the most lifesaving benefit from screening, they should adhere to a schedule of yearly mammograms beginning at age 40,” says Dr. Monsees. However, she also agrees with the ACS notation that clinicians should acknowledge that “different choices will be appropriate for different patients and that clinicians must help each patient arrive at a management decision consistent with her values and preferences.”¹

The word from an expert ObGyn
“By changing its guidance to begin screening at age 45 instead of 40, and in recommending biennial rather than annual screens in women 55 years of age and older, the updated ACS guidance will reduce harms (overdiagnosis and unnecessary additional imaging and biopsies) and moves closer to USPSTF guidance,” says Andrew M. Kaunitz, MD. He is University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville. He also serves on the OBG Management Board of Editors.

“As one editorialist points out, the ACS recommendation that women begin screening at age 45 years is based on observational comparisons of screened and unscreened cohorts—a type of analysis which the USPSTF does not consider due to concerns regarding bias,” notes Dr. Kaunitz.⁵

“The ACS recommendation for annual screening in women aged 45 to 54 is largely based on the findings of a report showing that, for premenopausal (but not postmenopausal) women, tumor stage was higher and size larger for screen-detected lesions among women undergoing biennial screens."⁶

As for the recommendation against screening CBE, Dr. Kaunitz considers that “a dramatic change from prior guidance. It is based on the absence of data finding benefits with CBE (alone or with screening mammography). Furthermore, the updated ACS guidance does not change its 2003 guidance, which does not support routine performance of or instruction regarding SBE.”

“These updated ACS guidelines should result in more women starting screening mammograms later in life, and they endorse biennial screening for many women, meaning that patients following ACS guidance will have fewer lifetime screens than with earlier recommendations,” says Dr. Kaunitz.

“Another plus is that performing fewer breast examinations during well-woman visits will allow us more time to assess family history and other risk factors for breast cancer, and to discuss screening recommendations.”

The bottom line
What is one to make of the many viewpoints on screening? For now, it probably is best to adhere to either the new ACS guidelines or current ACOG guidelines (TABLE 2), says OBG Management Editor in Chief Robert L. Barbieri, MD. He is chief of the Department of Obstetrics and Gynecology at Brigham and Women’s Hospital in Boston, and Kate Macy Ladd Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School.
 

ACOG recommends screening mammography every year for women starting at age 40. ACOG also states that “breast self-awareness has the potential to detect palpable breast cancer and can be recommended”; it also recommends CBE every year for women aged 19 or older.

These recommendations may change early next year, after ACOG convenes a consensus conference on the subject. The aim: “To develop a consistent set of uniform guidelines for breast cancer screening that can be implemented nationwide. Major organizations and providers of women’s health care, including ACS, will gather to evaluate and interpret the data in greater detail.”²

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

When the American Cancer Society (ACS) updated its guidelines for screening mammography earlier this week,¹ the effect was that of a stone being tossed into a tranquil pond, generating ripples in all directions.

The new guidelines focus on women at average risk for breast cancer (TABLE 1) and were updated for the first time since 2003, based on new evidence, a new emphasis on eliminating as many screening harms as possible, and a goal of “supporting the interplay among values, preferences, informed decision making, and recommendations.”¹ Earlier ACS guidelines recommended annual screening starting at age 40.
 

The new guidelines are graded according to the strength of the rec ommendation as being either “strong” or “qualified.” The ACS defines a “strong” recommendation as one that most individuals should follow. “Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator,” the guidelines note.¹

A “qualified” recommendation indicates that “Clinicians should acknowledge that different choices will be appropriate for different patients and that clinicians must help each patient arrive at a management decision consistent with her or his values and preferences.”¹

The recommendations are:

ACOG weighs in
Shortly after publication of the new ACS guidelines, the American College of Obstetricians and Gynecologists (ACOG) issued a formal statement in response²:

Response of the USPSTF
The US Preventive Services Task Force (USPSTF) also issued a statement in response to the new ACS guidelines:

The USPSTF currently recommends biennial screening beginning at age 50.

A leader in breast health cites pros and cons of ACS recommendations
Mark Pearlman, MD, professor of obstetrics and gynecology at the University of Michigan health system, is a nationally recognized expert on breast cancer screening. He sits on the National Comprehensive Cancer Network (NCCN) breast cancer screening and diagnosis group, helped author ACOG guidelines on mammography screening, and serves as a Contributing Editor to OBG Management.

“I believe the overall ACS mammography benefit evidence synthesis is reasonable and is in keeping with both NCCN and ACOG’s current recommendations. NCCN and ACOG mammography screening recommendations have both valued lives saved more highly than the ‘harms’ such as recalls and needle biopsies,” Dr. Pearlman says.

“If one combines ACS ‘strong’ and ‘qualified’ recommendations, ACS recommendations are similar to current ACOG and NCCN recommendations for mammography,” he adds.

Dr. Pearlman finds 7 areas of agreement between NCCN/ACOG and ACS recommendations, using both strong and qualified recommendations:

Where the ACS and ACOG/NCCN disagree is over the issue of the physical exam (abandoning CBE in average-risk women).

In regard to this last item, Dr. Pearlman says, “The ACS made a qualified recommendation against clinical breast exam. There is no high-level data to support such a marked change in practice. For example, when recommendations against breast self-examinations (BSE) were made, there were randomized controlled trials (RCTs) showing a lack of benefit and significant harms with BSE. With RCT-level data, it made sense to make a recommendation against the long-taught practice of SBE in average-risk women. That was not the case here. In fact, there are small amounts of data showing benefits of clinical breast exam.”

“One of my biggest concerns is not just the recommendation against CBE,” says Dr. Pearlman, “but that this may lead many women to interpret [this statement] as if they do not need to see their health care provider anymore. As you may recall, the American College of Physicians (ACP) recommended against annual pelvic examinations in asymptomatic patients. The ACS recommendation statement—taken together with the ACP statement—basically suggests that average-risk women don’t ever need to see a provider for a pelvic or breast examination except every 5 years for a Pap smear. That thinking does not recognize the importance of the clinical encounter (not just the CBE or pelvic exam), which is the opportunity to perform risk assessment and provide risk-reduction recommendations and healthy lifestyle recommendations.”

Radiologists resist new recommendations
Although the American College of Radiology (ACR) and the Society of Breast Imaging (SBI) agree with the ACS that mammography screening saves lives and should be available to women aged 40 and older, the 2 imaging organizations continue to recommend that annual screening begin at age 40. Their rationale: The latest ACS breast cancer screening guidelines, and earlier data used by the USPSTF to create its recommendations, both note that starting annual mammography at age 40 “saves the most lives.”

Where the organizations differ from the ACR is summed up by a formal statement on the ACR Web site: “The ACR and SBI strongly encourage women to obtain the maximum lifesaving benefits from mammography by continuing to get annual screening.”⁴

When OBG Management touched base with radiologist Barbara Monsees, MD, professor of radiology and Evens Professor of Women’s Health at Washington University Medical Center in St. Louis, Missouri, she expressed dismay at early news reports on the ACS guidelines.

“I’m dismayed that the headlines don’t seem to correlate with what the ACS actually recommended. The ACS did not state that women should wait until age 45 to begin screening. I believe the ACS was going for a more nuanced approach, but since that’s a bit complicated, I think that reporters have misconstrued what was intended,” Dr. Monsees says.

“The ACS guideline says that women between 40 and 44 years should have the opportunity to begin annual screening,” she says, noting that this recommendation was graded as “qualified.”

“The ACS states that a qualified recommendation indicates that ‘there is clear evidence of benefit of screening, but less certainty about the balance of benefits and harms, or about patients’ values and preferences, which could lead to different decisions about screening.’” The guideline also articulates the view “that the meaning of a qualified recommendation for patients is that the ‘majority of individuals in this situation would want the suggested course of action, but many would not.’ Therefore, I find it mind-boggling that this has been interpreted to mean that women should not begin screening until age 45.”¹

“It is my opinion that it is clear that if women want to achieve the most lifesaving benefit from screening, they should adhere to a schedule of yearly mammograms beginning at age 40,” says Dr. Monsees. However, she also agrees with the ACS notation that clinicians should acknowledge that “different choices will be appropriate for different patients and that clinicians must help each patient arrive at a management decision consistent with her values and preferences.”¹

The word from an expert ObGyn
“By changing its guidance to begin screening at age 45 instead of 40, and in recommending biennial rather than annual screens in women 55 years of age and older, the updated ACS guidance will reduce harms (overdiagnosis and unnecessary additional imaging and biopsies) and moves closer to USPSTF guidance,” says Andrew M. Kaunitz, MD. He is University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville. He also serves on the OBG Management Board of Editors.

“As one editorialist points out, the ACS recommendation that women begin screening at age 45 years is based on observational comparisons of screened and unscreened cohorts—a type of analysis which the USPSTF does not consider due to concerns regarding bias,” notes Dr. Kaunitz.⁵

“The ACS recommendation for annual screening in women aged 45 to 54 is largely based on the findings of a report showing that, for premenopausal (but not postmenopausal) women, tumor stage was higher and size larger for screen-detected lesions among women undergoing biennial screens."⁶

As for the recommendation against screening CBE, Dr. Kaunitz considers that “a dramatic change from prior guidance. It is based on the absence of data finding benefits with CBE (alone or with screening mammography). Furthermore, the updated ACS guidance does not change its 2003 guidance, which does not support routine performance of or instruction regarding SBE.”

“These updated ACS guidelines should result in more women starting screening mammograms later in life, and they endorse biennial screening for many women, meaning that patients following ACS guidance will have fewer lifetime screens than with earlier recommendations,” says Dr. Kaunitz.

“Another plus is that performing fewer breast examinations during well-woman visits will allow us more time to assess family history and other risk factors for breast cancer, and to discuss screening recommendations.”

The bottom line
What is one to make of the many viewpoints on screening? For now, it probably is best to adhere to either the new ACS guidelines or current ACOG guidelines (TABLE 2), says OBG Management Editor in Chief Robert L. Barbieri, MD. He is chief of the Department of Obstetrics and Gynecology at Brigham and Women’s Hospital in Boston, and Kate Macy Ladd Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School.
 

ACOG recommends screening mammography every year for women starting at age 40. ACOG also states that “breast self-awareness has the potential to detect palpable breast cancer and can be recommended”; it also recommends CBE every year for women aged 19 or older.

These recommendations may change early next year, after ACOG convenes a consensus conference on the subject. The aim: “To develop a consistent set of uniform guidelines for breast cancer screening that can be implemented nationwide. Major organizations and providers of women’s health care, including ACS, will gather to evaluate and interpret the data in greater detail.”²

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

When the American Cancer Society (ACS) updated its guidelines for screening mammography earlier this week,¹ the effect was that of a stone being tossed into a tranquil pond, generating ripples in all directions.

The new guidelines focus on women at average risk for breast cancer (TABLE 1) and were updated for the first time since 2003, based on new evidence, a new emphasis on eliminating as many screening harms as possible, and a goal of “supporting the interplay among values, preferences, informed decision making, and recommendations.”¹ Earlier ACS guidelines recommended annual screening starting at age 40.
 

The new guidelines are graded according to the strength of the rec ommendation as being either “strong” or “qualified.” The ACS defines a “strong” recommendation as one that most individuals should follow. “Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator,” the guidelines note.¹

A “qualified” recommendation indicates that “Clinicians should acknowledge that different choices will be appropriate for different patients and that clinicians must help each patient arrive at a management decision consistent with her or his values and preferences.”¹

The recommendations are:

ACOG weighs in
Shortly after publication of the new ACS guidelines, the American College of Obstetricians and Gynecologists (ACOG) issued a formal statement in response²:

Response of the USPSTF
The US Preventive Services Task Force (USPSTF) also issued a statement in response to the new ACS guidelines:

The USPSTF currently recommends biennial screening beginning at age 50.

A leader in breast health cites pros and cons of ACS recommendations
Mark Pearlman, MD, professor of obstetrics and gynecology at the University of Michigan health system, is a nationally recognized expert on breast cancer screening. He sits on the National Comprehensive Cancer Network (NCCN) breast cancer screening and diagnosis group, helped author ACOG guidelines on mammography screening, and serves as a Contributing Editor to OBG Management.

“I believe the overall ACS mammography benefit evidence synthesis is reasonable and is in keeping with both NCCN and ACOG’s current recommendations. NCCN and ACOG mammography screening recommendations have both valued lives saved more highly than the ‘harms’ such as recalls and needle biopsies,” Dr. Pearlman says.

“If one combines ACS ‘strong’ and ‘qualified’ recommendations, ACS recommendations are similar to current ACOG and NCCN recommendations for mammography,” he adds.

Dr. Pearlman finds 7 areas of agreement between NCCN/ACOG and ACS recommendations, using both strong and qualified recommendations:

Where the ACS and ACOG/NCCN disagree is over the issue of the physical exam (abandoning CBE in average-risk women).

In regard to this last item, Dr. Pearlman says, “The ACS made a qualified recommendation against clinical breast exam. There is no high-level data to support such a marked change in practice. For example, when recommendations against breast self-examinations (BSE) were made, there were randomized controlled trials (RCTs) showing a lack of benefit and significant harms with BSE. With RCT-level data, it made sense to make a recommendation against the long-taught practice of SBE in average-risk women. That was not the case here. In fact, there are small amounts of data showing benefits of clinical breast exam.”

“One of my biggest concerns is not just the recommendation against CBE,” says Dr. Pearlman, “but that this may lead many women to interpret [this statement] as if they do not need to see their health care provider anymore. As you may recall, the American College of Physicians (ACP) recommended against annual pelvic examinations in asymptomatic patients. The ACS recommendation statement—taken together with the ACP statement—basically suggests that average-risk women don’t ever need to see a provider for a pelvic or breast examination except every 5 years for a Pap smear. That thinking does not recognize the importance of the clinical encounter (not just the CBE or pelvic exam), which is the opportunity to perform risk assessment and provide risk-reduction recommendations and healthy lifestyle recommendations.”

Radiologists resist new recommendations
Although the American College of Radiology (ACR) and the Society of Breast Imaging (SBI) agree with the ACS that mammography screening saves lives and should be available to women aged 40 and older, the 2 imaging organizations continue to recommend that annual screening begin at age 40. Their rationale: The latest ACS breast cancer screening guidelines, and earlier data used by the USPSTF to create its recommendations, both note that starting annual mammography at age 40 “saves the most lives.”

Where the organizations differ from the ACR is summed up by a formal statement on the ACR Web site: “The ACR and SBI strongly encourage women to obtain the maximum lifesaving benefits from mammography by continuing to get annual screening.”⁴

When OBG Management touched base with radiologist Barbara Monsees, MD, professor of radiology and Evens Professor of Women’s Health at Washington University Medical Center in St. Louis, Missouri, she expressed dismay at early news reports on the ACS guidelines.

“I’m dismayed that the headlines don’t seem to correlate with what the ACS actually recommended. The ACS did not state that women should wait until age 45 to begin screening. I believe the ACS was going for a more nuanced approach, but since that’s a bit complicated, I think that reporters have misconstrued what was intended,” Dr. Monsees says.

“The ACS guideline says that women between 40 and 44 years should have the opportunity to begin annual screening,” she says, noting that this recommendation was graded as “qualified.”

“The ACS states that a qualified recommendation indicates that ‘there is clear evidence of benefit of screening, but less certainty about the balance of benefits and harms, or about patients’ values and preferences, which could lead to different decisions about screening.’” The guideline also articulates the view “that the meaning of a qualified recommendation for patients is that the ‘majority of individuals in this situation would want the suggested course of action, but many would not.’ Therefore, I find it mind-boggling that this has been interpreted to mean that women should not begin screening until age 45.”¹

“It is my opinion that it is clear that if women want to achieve the most lifesaving benefit from screening, they should adhere to a schedule of yearly mammograms beginning at age 40,” says Dr. Monsees. However, she also agrees with the ACS notation that clinicians should acknowledge that “different choices will be appropriate for different patients and that clinicians must help each patient arrive at a management decision consistent with her values and preferences.”¹

The word from an expert ObGyn
“By changing its guidance to begin screening at age 45 instead of 40, and in recommending biennial rather than annual screens in women 55 years of age and older, the updated ACS guidance will reduce harms (overdiagnosis and unnecessary additional imaging and biopsies) and moves closer to USPSTF guidance,” says Andrew M. Kaunitz, MD. He is University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville. He also serves on the OBG Management Board of Editors.

“As one editorialist points out, the ACS recommendation that women begin screening at age 45 years is based on observational comparisons of screened and unscreened cohorts—a type of analysis which the USPSTF does not consider due to concerns regarding bias,” notes Dr. Kaunitz.⁵

“The ACS recommendation for annual screening in women aged 45 to 54 is largely based on the findings of a report showing that, for premenopausal (but not postmenopausal) women, tumor stage was higher and size larger for screen-detected lesions among women undergoing biennial screens."⁶

As for the recommendation against screening CBE, Dr. Kaunitz considers that “a dramatic change from prior guidance. It is based on the absence of data finding benefits with CBE (alone or with screening mammography). Furthermore, the updated ACS guidance does not change its 2003 guidance, which does not support routine performance of or instruction regarding SBE.”

“These updated ACS guidelines should result in more women starting screening mammograms later in life, and they endorse biennial screening for many women, meaning that patients following ACS guidance will have fewer lifetime screens than with earlier recommendations,” says Dr. Kaunitz.

“Another plus is that performing fewer breast examinations during well-woman visits will allow us more time to assess family history and other risk factors for breast cancer, and to discuss screening recommendations.”

The bottom line
What is one to make of the many viewpoints on screening? For now, it probably is best to adhere to either the new ACS guidelines or current ACOG guidelines (TABLE 2), says OBG Management Editor in Chief Robert L. Barbieri, MD. He is chief of the Department of Obstetrics and Gynecology at Brigham and Women’s Hospital in Boston, and Kate Macy Ladd Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School.
 

ACOG recommends screening mammography every year for women starting at age 40. ACOG also states that “breast self-awareness has the potential to detect palpable breast cancer and can be recommended”; it also recommends CBE every year for women aged 19 or older.

These recommendations may change early next year, after ACOG convenes a consensus conference on the subject. The aim: “To develop a consistent set of uniform guidelines for breast cancer screening that can be implemented nationwide. Major organizations and providers of women’s health care, including ACS, will gather to evaluate and interpret the data in greater detail.”²

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Compared to the general population, women with mutations in the BRCA1 or BRCA2 genes have a significantly higher lifetime risk of ovarian and breast cancers (Science. 2003 Oct 24;302[5645]:643-6). Since the occurrence of ovarian and breast cancer in BRCA carriers is often prior to menopause, and because we have no screening test to detect early stage ovarian cancer, risk-reducing salpingo-oophorectomy has been recommended around age 40.

It has been shown that risk-reducing salpingo-oophorectomy significantly reduces ovarian cancer risk by 85%-95% in BRCA-affected women. Also, this surgery can reduce breast cancer risk by 53%-68% (N Engl J Med. 2002 May 23;346[21]:1609-15). The 2008 Practice Bulletin from the American College of Obstetricians and Gynecologists recommends that risk-reducing salpingo-oophorectomy should be performed in women with BRCA1 or BRCA2 mutations after the completion of childbearing or age 40 (Obstet Gynecol. 2008 Jan;111[1]:231-41).

Health implications

Nearly 60% of women who have a BRCA1 or BRCA2 mutation will elect to undergo risk-reducing salpingo-oophorectomy between the ages of 35 and 40 years (Open Med. 2007 Aug 13;1[2]:e92-8). As such, surgical menopause can result in hot flashes, vaginal dryness, sexual dysfunction, sleep disturbances, and cognitive changes, which may significantly impact a woman’s quality of life. In addition, increased risk of cardiovascular disease and osteoporosis following bilateral salpingo-oophorectomy may have a significant impact on a woman’s health.

Since these women undergo surgical menopause as opposed to natural menopause, they have an abrupt loss in hormones, and due to their younger age at the time of surgery, they may also have a longer exposure period to the detrimental effects of hypoestrogenism.

Symptom management

Various treatment options exist for relief of menopausal symptoms, including nonhormonal therapies and hormone replacement therapies (HT).

Nonhormonal therapies include serotonin receptor inhibitors (venlafaxine and paroxetine) and alpha-2 adrenergic agonists (clonidine), which are most appropriate for the treatment of vasomotor symptoms. Unfortunately, these options have proved to be as effective as HT. Also, women should be adequately counseled regarding the various side effects of these nonhormonal medications. Alternative approaches such as phytoestrogens are unproven and are still undergoing investigation. As such, HT remains the standard for treatment of menopausal symptoms, and many trials have confirmed that HT can effectively treat menopausal symptoms following risk-reducing salpingo-oophorectomy.

This then raises the question of safety regarding use of HT in this patient population; especially the possibility of increased risk of breast cancer. Interestingly, only 10%-25% of BRCA1 carriers will have estrogen receptor–positive breast cancer, while 65%-79% of BRCA2-associated breast cancers will be positive for the receptor (Clin Cancer Res. 2004 Mar 15;10[6]:2029-34).

Unfortunately, we do not have adequate trials or studies with sufficient long-term follow-up to validate whether HT increases the risk of breast cancer or recurrence. However, the PROSE Study Group did report on a prospective cohort of 462 women with BRCA1 or BRCA2 mutations. In this study, HT did not alter the reduction in breast cancer risk from risk-reducing salpingo-oophorectomy (J Clin Oncol. 2005 Nov 1;23[31]:7804-10). In addition to a paucity of data regarding systemic HT, there is little data in the BRCA-positive population to confirm the safety of local vaginal estrogen for treatment of vaginal atrophy (J Clin Oncol. 2004 Mar 15;22[6]:1045-54).

Understanding the options

Use of HT in women with BRCA1 and BRCA2 mutations requires further investigation. There should be shared decision making between the patient and provider when counseling on the management of menopausal symptoms following risk-reducing salpingo-oophorectomy. Most importantly, women should understand the options of nonhormonal therapies and their specific side effects. They should also understand the lack of significant data regarding use of systemic HT, and that if use is elected, there may be an increased risk of breast cancer.

Women who do elect to use systemic HT following risk-reducing salpingo-oophorectomy have options that can help reduce the risk of HT-associated breast cancer, including a shorter duration of systemic HT or concurrent hysterectomy to allow for estrogen-only HT, which has a decreased risk of breast cancer compared with combined therapies that include progestins. These women may also be considering prophylactic mastectomy, which would change the concerns regarding HT and an increased risk of breast cancer.

Increased awareness of these options among physicians and patients alike can help to decrease unsatisfactory symptoms and improve quality of life in women undergoing risk-reducing salpingo-oophorectomy.

Dr. Staley is a resident physician in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. They reported having no relevant financial disclosures. Email them at [email protected].

Compared to the general population, women with mutations in the BRCA1 or BRCA2 genes have a significantly higher lifetime risk of ovarian and breast cancers (Science. 2003 Oct 24;302[5645]:643-6). Since the occurrence of ovarian and breast cancer in BRCA carriers is often prior to menopause, and because we have no screening test to detect early stage ovarian cancer, risk-reducing salpingo-oophorectomy has been recommended around age 40.

It has been shown that risk-reducing salpingo-oophorectomy significantly reduces ovarian cancer risk by 85%-95% in BRCA-affected women. Also, this surgery can reduce breast cancer risk by 53%-68% (N Engl J Med. 2002 May 23;346[21]:1609-15). The 2008 Practice Bulletin from the American College of Obstetricians and Gynecologists recommends that risk-reducing salpingo-oophorectomy should be performed in women with BRCA1 or BRCA2 mutations after the completion of childbearing or age 40 (Obstet Gynecol. 2008 Jan;111[1]:231-41).

Health implications

Nearly 60% of women who have a BRCA1 or BRCA2 mutation will elect to undergo risk-reducing salpingo-oophorectomy between the ages of 35 and 40 years (Open Med. 2007 Aug 13;1[2]:e92-8). As such, surgical menopause can result in hot flashes, vaginal dryness, sexual dysfunction, sleep disturbances, and cognitive changes, which may significantly impact a woman’s quality of life. In addition, increased risk of cardiovascular disease and osteoporosis following bilateral salpingo-oophorectomy may have a significant impact on a woman’s health.

Since these women undergo surgical menopause as opposed to natural menopause, they have an abrupt loss in hormones, and due to their younger age at the time of surgery, they may also have a longer exposure period to the detrimental effects of hypoestrogenism.

Symptom management

Various treatment options exist for relief of menopausal symptoms, including nonhormonal therapies and hormone replacement therapies (HT).

Nonhormonal therapies include serotonin receptor inhibitors (venlafaxine and paroxetine) and alpha-2 adrenergic agonists (clonidine), which are most appropriate for the treatment of vasomotor symptoms. Unfortunately, these options have proved to be as effective as HT. Also, women should be adequately counseled regarding the various side effects of these nonhormonal medications. Alternative approaches such as phytoestrogens are unproven and are still undergoing investigation. As such, HT remains the standard for treatment of menopausal symptoms, and many trials have confirmed that HT can effectively treat menopausal symptoms following risk-reducing salpingo-oophorectomy.

This then raises the question of safety regarding use of HT in this patient population; especially the possibility of increased risk of breast cancer. Interestingly, only 10%-25% of BRCA1 carriers will have estrogen receptor–positive breast cancer, while 65%-79% of BRCA2-associated breast cancers will be positive for the receptor (Clin Cancer Res. 2004 Mar 15;10[6]:2029-34).

Unfortunately, we do not have adequate trials or studies with sufficient long-term follow-up to validate whether HT increases the risk of breast cancer or recurrence. However, the PROSE Study Group did report on a prospective cohort of 462 women with BRCA1 or BRCA2 mutations. In this study, HT did not alter the reduction in breast cancer risk from risk-reducing salpingo-oophorectomy (J Clin Oncol. 2005 Nov 1;23[31]:7804-10). In addition to a paucity of data regarding systemic HT, there is little data in the BRCA-positive population to confirm the safety of local vaginal estrogen for treatment of vaginal atrophy (J Clin Oncol. 2004 Mar 15;22[6]:1045-54).

Understanding the options

Use of HT in women with BRCA1 and BRCA2 mutations requires further investigation. There should be shared decision making between the patient and provider when counseling on the management of menopausal symptoms following risk-reducing salpingo-oophorectomy. Most importantly, women should understand the options of nonhormonal therapies and their specific side effects. They should also understand the lack of significant data regarding use of systemic HT, and that if use is elected, there may be an increased risk of breast cancer.

Women who do elect to use systemic HT following risk-reducing salpingo-oophorectomy have options that can help reduce the risk of HT-associated breast cancer, including a shorter duration of systemic HT or concurrent hysterectomy to allow for estrogen-only HT, which has a decreased risk of breast cancer compared with combined therapies that include progestins. These women may also be considering prophylactic mastectomy, which would change the concerns regarding HT and an increased risk of breast cancer.

Increased awareness of these options among physicians and patients alike can help to decrease unsatisfactory symptoms and improve quality of life in women undergoing risk-reducing salpingo-oophorectomy.

Dr. Staley is a resident physician in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. They reported having no relevant financial disclosures. Email them at [email protected].

Compared to the general population, women with mutations in the BRCA1 or BRCA2 genes have a significantly higher lifetime risk of ovarian and breast cancers (Science. 2003 Oct 24;302[5645]:643-6). Since the occurrence of ovarian and breast cancer in BRCA carriers is often prior to menopause, and because we have no screening test to detect early stage ovarian cancer, risk-reducing salpingo-oophorectomy has been recommended around age 40.

It has been shown that risk-reducing salpingo-oophorectomy significantly reduces ovarian cancer risk by 85%-95% in BRCA-affected women. Also, this surgery can reduce breast cancer risk by 53%-68% (N Engl J Med. 2002 May 23;346[21]:1609-15). The 2008 Practice Bulletin from the American College of Obstetricians and Gynecologists recommends that risk-reducing salpingo-oophorectomy should be performed in women with BRCA1 or BRCA2 mutations after the completion of childbearing or age 40 (Obstet Gynecol. 2008 Jan;111[1]:231-41).

Health implications

Nearly 60% of women who have a BRCA1 or BRCA2 mutation will elect to undergo risk-reducing salpingo-oophorectomy between the ages of 35 and 40 years (Open Med. 2007 Aug 13;1[2]:e92-8). As such, surgical menopause can result in hot flashes, vaginal dryness, sexual dysfunction, sleep disturbances, and cognitive changes, which may significantly impact a woman’s quality of life. In addition, increased risk of cardiovascular disease and osteoporosis following bilateral salpingo-oophorectomy may have a significant impact on a woman’s health.

Since these women undergo surgical menopause as opposed to natural menopause, they have an abrupt loss in hormones, and due to their younger age at the time of surgery, they may also have a longer exposure period to the detrimental effects of hypoestrogenism.

Symptom management

Various treatment options exist for relief of menopausal symptoms, including nonhormonal therapies and hormone replacement therapies (HT).

Nonhormonal therapies include serotonin receptor inhibitors (venlafaxine and paroxetine) and alpha-2 adrenergic agonists (clonidine), which are most appropriate for the treatment of vasomotor symptoms. Unfortunately, these options have proved to be as effective as HT. Also, women should be adequately counseled regarding the various side effects of these nonhormonal medications. Alternative approaches such as phytoestrogens are unproven and are still undergoing investigation. As such, HT remains the standard for treatment of menopausal symptoms, and many trials have confirmed that HT can effectively treat menopausal symptoms following risk-reducing salpingo-oophorectomy.

This then raises the question of safety regarding use of HT in this patient population; especially the possibility of increased risk of breast cancer. Interestingly, only 10%-25% of BRCA1 carriers will have estrogen receptor–positive breast cancer, while 65%-79% of BRCA2-associated breast cancers will be positive for the receptor (Clin Cancer Res. 2004 Mar 15;10[6]:2029-34).

Unfortunately, we do not have adequate trials or studies with sufficient long-term follow-up to validate whether HT increases the risk of breast cancer or recurrence. However, the PROSE Study Group did report on a prospective cohort of 462 women with BRCA1 or BRCA2 mutations. In this study, HT did not alter the reduction in breast cancer risk from risk-reducing salpingo-oophorectomy (J Clin Oncol. 2005 Nov 1;23[31]:7804-10). In addition to a paucity of data regarding systemic HT, there is little data in the BRCA-positive population to confirm the safety of local vaginal estrogen for treatment of vaginal atrophy (J Clin Oncol. 2004 Mar 15;22[6]:1045-54).

Understanding the options

Use of HT in women with BRCA1 and BRCA2 mutations requires further investigation. There should be shared decision making between the patient and provider when counseling on the management of menopausal symptoms following risk-reducing salpingo-oophorectomy. Most importantly, women should understand the options of nonhormonal therapies and their specific side effects. They should also understand the lack of significant data regarding use of systemic HT, and that if use is elected, there may be an increased risk of breast cancer.

Women who do elect to use systemic HT following risk-reducing salpingo-oophorectomy have options that can help reduce the risk of HT-associated breast cancer, including a shorter duration of systemic HT or concurrent hysterectomy to allow for estrogen-only HT, which has a decreased risk of breast cancer compared with combined therapies that include progestins. These women may also be considering prophylactic mastectomy, which would change the concerns regarding HT and an increased risk of breast cancer.

Increased awareness of these options among physicians and patients alike can help to decrease unsatisfactory symptoms and improve quality of life in women undergoing risk-reducing salpingo-oophorectomy.

Dr. Staley is a resident physician in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. They reported having no relevant financial disclosures. Email them at [email protected].

The new American Cancer Society (ACS) policy for mammography screening now recommends annual mammograms from age 45 until age 54, suggesting a less aggressive approach to screening than in the 2003 guidelines. The recommendation is for asymptomatic women at average risk of developing breast cancer.

Related: How Much Is Too Much Cancer Screening?

“These recommendations are made with the intent of maximizing reductions in breast cancer mortality and years of life saved while being attentive to the need to minimize harms associated with screening,” said Dr. Kevin C. Oeffinger, chairman of the breast cancer guideline panel.

Related: Advances in Targeted Therapy for Breast Cancer

The guideline, developed by a panel of outside experts, was published October 20, 2015, in The Journal of the American Medical Association.

Other important recommendation changes include:

• ŸWomen aged 45 to 54 years should receive annual screening mammography and at age 55 women should transition to biennial screening.
• ŸWomen should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer.
• ŸClinical breast examination is no longer recommended at any age.
• ŸThe panel noted that the recommendations are an effort to avoid false positive findings, which can take an emotional toll.

The current VHA recommendations state:

• Mammography is not recommended for women aged 13 to 39 years.
• Women aged 40 to 49 years should talk with their health care providers about screening.
• ŸMammograms are recommended every 2 years for women aged 50 to 74 years.
• ŸWomen aged > 75 years should talk with their health care providers.

According to Anita Aggarwal, DO, PhD, president of the Association of VA Hematology and Oncology (AVAHO), the VHA recommendations leave a lot of wiggle room; every year starting at age 40 is still acceptable practice at the VA.

Related: Breast Cancer Research Group Aims to Improve Veteran Survival Rates

“Keep in mind that recommendations are just recommendations,” Dr. Aggarwal told Federal Practitioner. “One size may not fit all. I believe we should use our sound judgment based on valid research to recommend what is best for the patient. Based on my literature search, annual screening starting at 40 saves the most lives via early detection.”

The new American Cancer Society (ACS) policy for mammography screening now recommends annual mammograms from age 45 until age 54, suggesting a less aggressive approach to screening than in the 2003 guidelines. The recommendation is for asymptomatic women at average risk of developing breast cancer.

Related: How Much Is Too Much Cancer Screening?

“These recommendations are made with the intent of maximizing reductions in breast cancer mortality and years of life saved while being attentive to the need to minimize harms associated with screening,” said Dr. Kevin C. Oeffinger, chairman of the breast cancer guideline panel.

Related: Advances in Targeted Therapy for Breast Cancer

The guideline, developed by a panel of outside experts, was published October 20, 2015, in The Journal of the American Medical Association.

Other important recommendation changes include:

• ŸWomen aged 45 to 54 years should receive annual screening mammography and at age 55 women should transition to biennial screening.
• ŸWomen should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer.
• ŸClinical breast examination is no longer recommended at any age.
• ŸThe panel noted that the recommendations are an effort to avoid false positive findings, which can take an emotional toll.

The current VHA recommendations state:

• Mammography is not recommended for women aged 13 to 39 years.
• Women aged 40 to 49 years should talk with their health care providers about screening.
• ŸMammograms are recommended every 2 years for women aged 50 to 74 years.
• ŸWomen aged > 75 years should talk with their health care providers.

According to Anita Aggarwal, DO, PhD, president of the Association of VA Hematology and Oncology (AVAHO), the VHA recommendations leave a lot of wiggle room; every year starting at age 40 is still acceptable practice at the VA.

Related: Breast Cancer Research Group Aims to Improve Veteran Survival Rates

“Keep in mind that recommendations are just recommendations,” Dr. Aggarwal told Federal Practitioner. “One size may not fit all. I believe we should use our sound judgment based on valid research to recommend what is best for the patient. Based on my literature search, annual screening starting at 40 saves the most lives via early detection.”

The new American Cancer Society (ACS) policy for mammography screening now recommends annual mammograms from age 45 until age 54, suggesting a less aggressive approach to screening than in the 2003 guidelines. The recommendation is for asymptomatic women at average risk of developing breast cancer.

Related: How Much Is Too Much Cancer Screening?

“These recommendations are made with the intent of maximizing reductions in breast cancer mortality and years of life saved while being attentive to the need to minimize harms associated with screening,” said Dr. Kevin C. Oeffinger, chairman of the breast cancer guideline panel.

Related: Advances in Targeted Therapy for Breast Cancer

The guideline, developed by a panel of outside experts, was published October 20, 2015, in The Journal of the American Medical Association.

Other important recommendation changes include:

• ŸWomen aged 45 to 54 years should receive annual screening mammography and at age 55 women should transition to biennial screening.
• ŸWomen should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer.
• ŸClinical breast examination is no longer recommended at any age.
• ŸThe panel noted that the recommendations are an effort to avoid false positive findings, which can take an emotional toll.

The current VHA recommendations state:

• Mammography is not recommended for women aged 13 to 39 years.
• Women aged 40 to 49 years should talk with their health care providers about screening.
• ŸMammograms are recommended every 2 years for women aged 50 to 74 years.
• ŸWomen aged > 75 years should talk with their health care providers.

According to Anita Aggarwal, DO, PhD, president of the Association of VA Hematology and Oncology (AVAHO), the VHA recommendations leave a lot of wiggle room; every year starting at age 40 is still acceptable practice at the VA.

Related: Breast Cancer Research Group Aims to Improve Veteran Survival Rates

“Keep in mind that recommendations are just recommendations,” Dr. Aggarwal told Federal Practitioner. “One size may not fit all. I believe we should use our sound judgment based on valid research to recommend what is best for the patient. Based on my literature search, annual screening starting at 40 saves the most lives via early detection.”

Among postmenopausal women, breast cancers diagnosed following biennial mammography intervals are no more “unfavorable” than those diagnosed following annual intervals, according to a report published online Oct. 20 in JAMA Oncology.

“When considering recommendations regarding screening intervals, the potential benefit of diagnosing cancers at an earlier stage must be weighed against the increased potential for harms associated with more frequent screening, such as false-positive recalls and biopsies, which are 1.5 to 2 times higher in annual vs. biennial screeners,” wrote Diana L. Miglioretti, Ph.D., of the University of California, Davis, and her associates in the Breast Cancer Surveillance Consortium (BCSC).

Dr. Cecil Fox/National Cancer Institute

The optimal frequency of mammographic screening remains controversial. The American Cancer Society commissioned the BCSC to analyze the most recent information on this issue as part of its effort to update the ACS guideline for breast cancer screening for women at average risk.

BCSC registries collect patient and clinical data from community radiology facilities across the country. For this analysis, Dr. Miglioretti and her colleagues focused on 15,440 women aged 40-85 years in these registries who were diagnosed as having breast cancer from 1996 to 2012. A total of 12,070 of the women underwent annual mammographic screening and 3,370 underwent biennial mammographic screening.

Among premenopausal women, those diagnosed after biennial mammograms were more likely to have tumors with unfavorable prognostic characteristics than were those diagnosed after annual mammograms (relative risk, 1.11). In contrast, among postmenopausal women, those diagnosed after biennial mammograms were not more likely to have tumors with unfavorable prognostic characteristics than were those diagnosed after annual mammograms (RR, 1.03), the investigators wrote (JAMA Oncol. 2015 Oct 20. doi: 10.1001/jamaoncology.2015.3084).

In an editorial accompanying this report, Dr. Wendy Y. Chen of Brigham and Women’s Hospital, Dana Farber Cancer Institute, and Harvard Medical School, all in Boston, wrote, “Although the authors do not endorse annual or biennial screening, they imply that biennial screening would be acceptable for postmenopausal women but inferior for premenopausal women.”

Most developed countries outside the United States – including the United Kingdom, Canada, and Australia – recommend screening every 2 or 3 years, Dr. Chen noted (JAMA Oncol. 2015 Oct 20 doi: 10.1001/jamaoncology.2015.3286).

This study and others clearly show that, with less frequent mammography, breast cancers will be larger and have a slightly more advanced stage when they are discovered, Dr. Chen wrote. But with a better understanding of tumor biology and improvements in targeted therapy, the best approach may not be simply trying to identify a smaller tumor, she added.

“Efforts should be focused on a better understanding of how screening interacts with tumor biology with a better understanding of the types of interval cancers and sojourn times and how these characteristics differ by age and/or menopausal status,” Dr. Chen wrote.

This study was supported by the American Cancer Society and the National Cancer Institute. Dr. Miglioretti reported having no relevant financial disclosures. One of the investigators reported being an unpaid advisor on General Electric Health Care’s breast medical advisory board.

Among postmenopausal women, breast cancers diagnosed following biennial mammography intervals are no more “unfavorable” than those diagnosed following annual intervals, according to a report published online Oct. 20 in JAMA Oncology.

“When considering recommendations regarding screening intervals, the potential benefit of diagnosing cancers at an earlier stage must be weighed against the increased potential for harms associated with more frequent screening, such as false-positive recalls and biopsies, which are 1.5 to 2 times higher in annual vs. biennial screeners,” wrote Diana L. Miglioretti, Ph.D., of the University of California, Davis, and her associates in the Breast Cancer Surveillance Consortium (BCSC).

Dr. Cecil Fox/National Cancer Institute

The optimal frequency of mammographic screening remains controversial. The American Cancer Society commissioned the BCSC to analyze the most recent information on this issue as part of its effort to update the ACS guideline for breast cancer screening for women at average risk.

BCSC registries collect patient and clinical data from community radiology facilities across the country. For this analysis, Dr. Miglioretti and her colleagues focused on 15,440 women aged 40-85 years in these registries who were diagnosed as having breast cancer from 1996 to 2012. A total of 12,070 of the women underwent annual mammographic screening and 3,370 underwent biennial mammographic screening.

Among premenopausal women, those diagnosed after biennial mammograms were more likely to have tumors with unfavorable prognostic characteristics than were those diagnosed after annual mammograms (relative risk, 1.11). In contrast, among postmenopausal women, those diagnosed after biennial mammograms were not more likely to have tumors with unfavorable prognostic characteristics than were those diagnosed after annual mammograms (RR, 1.03), the investigators wrote (JAMA Oncol. 2015 Oct 20. doi: 10.1001/jamaoncology.2015.3084).

In an editorial accompanying this report, Dr. Wendy Y. Chen of Brigham and Women’s Hospital, Dana Farber Cancer Institute, and Harvard Medical School, all in Boston, wrote, “Although the authors do not endorse annual or biennial screening, they imply that biennial screening would be acceptable for postmenopausal women but inferior for premenopausal women.”

Most developed countries outside the United States – including the United Kingdom, Canada, and Australia – recommend screening every 2 or 3 years, Dr. Chen noted (JAMA Oncol. 2015 Oct 20 doi: 10.1001/jamaoncology.2015.3286).

This study and others clearly show that, with less frequent mammography, breast cancers will be larger and have a slightly more advanced stage when they are discovered, Dr. Chen wrote. But with a better understanding of tumor biology and improvements in targeted therapy, the best approach may not be simply trying to identify a smaller tumor, she added.

“Efforts should be focused on a better understanding of how screening interacts with tumor biology with a better understanding of the types of interval cancers and sojourn times and how these characteristics differ by age and/or menopausal status,” Dr. Chen wrote.

This study was supported by the American Cancer Society and the National Cancer Institute. Dr. Miglioretti reported having no relevant financial disclosures. One of the investigators reported being an unpaid advisor on General Electric Health Care’s breast medical advisory board.

Among postmenopausal women, breast cancers diagnosed following biennial mammography intervals are no more “unfavorable” than those diagnosed following annual intervals, according to a report published online Oct. 20 in JAMA Oncology.

“When considering recommendations regarding screening intervals, the potential benefit of diagnosing cancers at an earlier stage must be weighed against the increased potential for harms associated with more frequent screening, such as false-positive recalls and biopsies, which are 1.5 to 2 times higher in annual vs. biennial screeners,” wrote Diana L. Miglioretti, Ph.D., of the University of California, Davis, and her associates in the Breast Cancer Surveillance Consortium (BCSC).

Dr. Cecil Fox/National Cancer Institute

The optimal frequency of mammographic screening remains controversial. The American Cancer Society commissioned the BCSC to analyze the most recent information on this issue as part of its effort to update the ACS guideline for breast cancer screening for women at average risk.

BCSC registries collect patient and clinical data from community radiology facilities across the country. For this analysis, Dr. Miglioretti and her colleagues focused on 15,440 women aged 40-85 years in these registries who were diagnosed as having breast cancer from 1996 to 2012. A total of 12,070 of the women underwent annual mammographic screening and 3,370 underwent biennial mammographic screening.

Among premenopausal women, those diagnosed after biennial mammograms were more likely to have tumors with unfavorable prognostic characteristics than were those diagnosed after annual mammograms (relative risk, 1.11). In contrast, among postmenopausal women, those diagnosed after biennial mammograms were not more likely to have tumors with unfavorable prognostic characteristics than were those diagnosed after annual mammograms (RR, 1.03), the investigators wrote (JAMA Oncol. 2015 Oct 20. doi: 10.1001/jamaoncology.2015.3084).

In an editorial accompanying this report, Dr. Wendy Y. Chen of Brigham and Women’s Hospital, Dana Farber Cancer Institute, and Harvard Medical School, all in Boston, wrote, “Although the authors do not endorse annual or biennial screening, they imply that biennial screening would be acceptable for postmenopausal women but inferior for premenopausal women.”

Most developed countries outside the United States – including the United Kingdom, Canada, and Australia – recommend screening every 2 or 3 years, Dr. Chen noted (JAMA Oncol. 2015 Oct 20 doi: 10.1001/jamaoncology.2015.3286).

This study and others clearly show that, with less frequent mammography, breast cancers will be larger and have a slightly more advanced stage when they are discovered, Dr. Chen wrote. But with a better understanding of tumor biology and improvements in targeted therapy, the best approach may not be simply trying to identify a smaller tumor, she added.

“Efforts should be focused on a better understanding of how screening interacts with tumor biology with a better understanding of the types of interval cancers and sojourn times and how these characteristics differ by age and/or menopausal status,” Dr. Chen wrote.

This study was supported by the American Cancer Society and the National Cancer Institute. Dr. Miglioretti reported having no relevant financial disclosures. One of the investigators reported being an unpaid advisor on General Electric Health Care’s breast medical advisory board.