New Mammogram Guidelines for 40-Somethings

A new report suggests the risks of breast cancer screening could outweigh the benefits for women under 50, calling into question decades-old guidelines that women begin having regular mammograms at age 40.

The new American College of Physicians study recommends that women in their 40s talk to their doctors about whether to test, since younger women with no family history of breast cancer tend to be at low risk of developing the disease.

The report is sure to raise questions for middle-aged women and has already prompted debate among breast cancer specialists, many of whom argue the new guidelines will deter patients who should be getting exams from having them.

Already, less than 50 percent of women follow the current American Cancer Society guidelines recommending regular screening starting at 40.

"The new guidelines do not do a good job of discussing the balance between risk and benefits," said Dr. Monica Morrow, chairman of the department of surgical oncology at the Fox Chase Cancer Center.

While the guidelines do have scientific merit, they are "extremely impractical" because they don't offer clear guidance for doctors or women in their forties, she said.

The distinction between what is practical and what is most medically valuable has been at the heart of a long-standing debate over whether women under 50 benefit from screening. The new report suggests women may be harmed by radiation from testing, particularly the earlier and more frequently they are screened. The authors do point out that has been no definitive study linking small doses of radiation from mammograms to illness.

A clearer risk comes from getting a false positive -- a result that wrongly shows cancer in a perfectly healthy patient. It is estimated that false positives occur in about 2 to 4 percent of all mammograms. The results are traumatic for women and their families, and can lead to additional, unnecessary tests and even unnecessary therapies.

The more mammograms a woman has, the greater chance she has of getting a false positive.

For these reasons, many European countries have guidelines that recommend women wait until they turn 50 to get regular testing. "It is much more accurate after 50, because breast tissue becomes less dense after menopause," says Dr. Susan Love, who runs the Dr. Susan Love Research Foundation. She says the new recommendations "sound about right."

Still, a major concern among oncologists is that a change in long-standing guidelines will confuse patients. "Shifting guidelines confuses the general population, which is already cutting back on mammography compliance," said Dr. Marisa Weiss, president and founder of breastcancer.org.

Doctors and Patients Decide

The report's authors suggest patients and doctors should decide together whether to do the testing.

This would put too much control in the patients' hands and place "additional burden on an already overtaxed, overstressed primary care provider to counsel women," said Dr. Anthony Elias of the Colorado Cancer Center.

"I hope they ignore it, frankly, and continue to get annual mammograms," said Lillie Shockney, administrative director of the Johns Hopkins Avon Foundation Breast Center.

Early detection saves lives, and many women are already reluctant to get tested and so should be encouraged, not dissuaded, from starting early, she said.

One of the reasons it's so hard to create adequate guidelines for 40- to 49-year-olds is that while this group is at a low risk for breast cancer, those who do develop the disease often get it in a very aggressive form. Testing then may not decrease their chance of dying.

Still, "the cost of underdiagnosis is greatest in the youngest patients with the largest number of potential years of life to lose," said Clifford Hudis, chief of breast cancer medicine service at Memorial Sloan-Kettering Cancer Center.

The bottom line, said most clinicians, is that high-risk women -- those with a family history of breast cancer -- should be screened early, while those at lower risk of developing the disease may hold off on testing until age 50, depending on what they and their doctor decide.

The debate also underscores the need for better tests, according to many doctors. "I think it's time to recognize that imaging and early detection are concepts that need to be reassessed," said Love. "We need a test which will more reliably tell us who is at risk, so that we can prevent the disease."

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