Albert L. Siu, MD, MSPH; on behalf of the U.S. Preventive Services Task Force *
Disclaimer: Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Financial Support: The USPSTF is an independent, voluntary body. The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF.
Disclosures: Dr. Phillips disclosed that he has received past grants and contracts from NCI and CDC for research on patterns of use of screening tests for breast and other cancers in primary care. Dr. owens discloses that he has received travel reimbursement from the USPSTF. Authors followed the policy regarding conflicts of interest described at www.uspreventiveservicestaskforce.org/Page/Name/methods-and-processes. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-2886.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Update of the 2009 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for breast cancer.
The USPSTF reviewed the evidence on the following: effectiveness of breast cancer screening in reducing breast cancer–specific and all-cause mortality, as well as the incidence of advanced breast cancer and treatment-related morbidity; harms of breast cancer screening; test performance characteristics of digital breast tomosynthesis as a primary screening strategy; and adjunctive screening in women with increased breast density. In addition, the USPSTF reviewed comparative decision models on optimal starting and stopping ages and intervals for screening mammography; how breast density, breast cancer risk, and comorbidity level affect the balance of benefit and harms of screening mammography; and the number of radiation-induced breast cancer cases and deaths associated with different screening mammography strategies over the course of a woman's lifetime.
This recommendation applies to asymptomatic women aged 40 years or older who do not have preexisting breast cancer or a previously diagnosed high-risk breast lesion and who are not at high risk for breast cancer because of a known underlying genetic mutation (such as a BRCA1 or BRCA2 gene mutation or other familial breast cancer syndrome) or a history of chest radiation at a young age.
The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. (B recommendation)
The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years. (C recommendation)
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older. (I statement)
The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer. (I statement)
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging (MRI), DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram. (I statement)
Screening for breast cancer: clinical summary.
Appendix Table 1. What the USPSTF Grades Mean and Suggestions for Practice
Appendix Table 2. USPSTF Levels of Certainty Regarding Net Benefit
Table 1. Breast Cancer Deaths Avoided (95% CI) per 10 000 Women Screened by Repeat Screening Mammography Over 10 Years: Data From Randomized, Controlled Trials*
Trends in invasive and noninvasive breast cancer incidence and mortality since the widespread introduction of screening mammography in the United States.
The figure depicts changes in age-adjusted invasive and combined invasive and noninvasive breast cancer incidence and mortality rates in the United States from 1975 through 2011. The baseline breast cancer incidence rate was 105 to 111 cases per 100 000 women (depending on whether one considers invasive disease or invasive plus noninvasive disease together). With the widespread diffusion of mammography screening, this rate increased to 165 cases of noninvasive plus invasive disease per 100 000 women in 2011 (an excess of 54 to 60 cases per 100 000 women, or about a 50% increase). Breast cancer mortality rates have declined at a slower rate, from 31 to 22 cases (or a reduction of 9 deaths) per 100 000 women over the same time period. Based on data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program (5).
Table 2. Harms of One-Time Mammography Screening per 10 000 Women Screened: Breast Cancer Surveillance Consortium Registry Data
Table 3. Lifetime Benefits and Harms of Biennial Screening Mammography per 1000 Women Screened: Model Results Compared With No Screening*
Table 4. Lifetime Benefits and Harms of Annual Versus Biennial Screening Mammography per 1000 Women Screened: Model Results Compared With No Screening*
Table 5. Ten-Year Cumulative Probability (95% CI) of a False-Positive Test Result or Biopsy Recommendation From Annual or Biennial Mammography Screening Starting at Age 40 or 50 Years: Breast Cancer Surveillance Consortium Registry Data
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USPSTF Vice Chair, Dr. Kristen Bibbins-Domingo discusses final recommendations for mammography screening.
Arn Migowski,MD, MPH, Gulnar Azevedo e Silva, MD, MPH, PhD, Jose Eluf-Neto, MD, MSc, PhD
National Cancer Institute, Brazil
February 9, 2016
Breast Cancer Screening: Different Contexts Require Different Guidelines
With the publication of the US Preventive Services Task Force (USPSTF) (1) and American Cancer Society's (ACS) (2) new recommendations, physicians, researchers and decisions makers around the world are wondering about the applicability of these guidelines to their contexts.
The Brazilian Ministry of Health has just updated the guidelines for breast cancer early detection (3). The new recommendations were made after an extensive systematic review conducted by an interdisciplinary group, consisting of oncologists and epidemiologists among others and thorough assessment of benefits and harms. Biennial mammography screening was recommended for women aged between 50 and 69 years with average risk. Considering the insufficient direct evidence to assess its benefits in ages 70-74 and the lower life expectancy in Brazil, routine screening was not recommended in this group.
The main difference in the new USPSTF and ACS guidelines is the recommendation of ACS to start routine screening at age 45 (1, 2). Nevertheless, the use of incidence rates by age groups to support the recommendation of screening before age 50 as made by ACS (2) may be misleading due to the artificial increase of the incidence caused by lead time bias and overdiagnosis, since in both Brazil and the US many women start screening in their forties.
Even in Sao Paulo, one of the cities with the highest breast cancer incidence in the country (4), the specific rate among women of 45 to 49 years is 144.3 per 100,000, similar to the observed rate among those aged 40 to 44 in the US (2). As almost the entire world has lower breast cancer incidence rates than the US, ACS criteria also lacks external validity to other contexts.
Furthermore, in Brazil the results of mammographic screening tend to be worse than in the US due to the lower incidence of breast cancer and the difficulty of maintaining the quality of mammograms in the whole country. These conditions probably lead to an excess of false-positive and false-negative results and higher levels of radiation exposure, resulting in lower effectiveness of screening and greater harms.
Brazilian Guidelines (3) include interventions for symptomatic women, such as breast awareness, urgent referral from primary care and one-stop breast clinics, which are out of the scope of USPSTF and ACS guidelines, and are especially important in contexts where a great proportion of cases are diagnosed at advanced stages. Our guidelines seem appropriate to Brazil and countries with similar settings.
Authors’ contributions: AM, GAS, JEN drafted the manuscript. AM and GAS collected the data and calculated the incidence rate. All authors read and approved the final manuscript.
Arn Migowski. Division of Early Detection of Cancer, National Cancer Institute (INCA). Rua Marquês de Pombal 125, 20.230-092, Laranjeiras, Rio de Janeiro, RJ, Brazil.
Conflict of Interest Disclosures: none
1. Siu AL; U.S. Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016 Jan 12. doi: 10.7326/M15-2886.
2. Oeffinger KC, Fontham ETH, Etzioni R, Herzig A, Michaelson JS, Shyh Y-C T et al. Breast cancer screening for women at average risk: 2015 update from the American Cancer Society. JAMA. 2015; 314:1599-614.
3. Instituto Nacional de Câncer José Alencar Gomes da Silva. Diretrizes para a detecção precoce do câncer de mama no Brasil [Guidelines for the early detection of breast cancer in Brazil]. Rio de Janeiro: Instituto Nacional de Câncer José Alencar Gomes da Silva; 2015. 168 p. Portuguese. http://www1.inca.gov.br/inca/Arquivos/livro_deteccao_precoce_final.pdf Accessed November 13, 2015.
4. Forman D, Bray F, Brewster DH, Mbalawa CG, Kohler B, Piñeros M, et al., eds. Cancer Incidence in Five Continents, Vol. X. IARC Scientific Publication No. 164. Lyon: International Agency for Research on Cancer; 2014.
Siu AL, on behalf of the U.S. Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164:279–296. [Epub ahead of print 12 January 2016]. doi: 10.7326/M15-2886
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Published: Ann Intern Med. 2016;164(4):279-296.
Published at www.annals.org on 12 January 2016
Breast Cancer, Cancer Screening/Prevention, Guidelines, Hematology/Oncology, Prevention/Screening.
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