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Biennial Breast Cancer Screening Reaffirmed

USPSTF stands fast on its 2009 recommendation.

Women between the ages of 50 and 74, with an average risk of breast cancer, should have screening mammography only every two years, the U.S. Preventive Services Task Force (USPSTF) again recommended.

THE VIEW FROM DUKE

SHELLEY HWANG, MD, MPH, Surgical Oncologist, Duke

No Insurance Coverage Changes Yet
The USPSTF is a panel of experts convened in 1984 to provide recommendations about important topics in screening and other preventive interventions that impact the nation's health. In its 2015 update for breast cancer screening, the USPSTF continues to recommend that routine screening mammography be performed only every two years between the ages of 50 and 74, and that screening mammography between the ages of 40 and 49 be based on individual risk factors. These guidelines continue to be controversial, and several other professional organizations, including the American Cancer Society, the American Congress of Obstetricians and Gynecologists, and the American College of Radiology, continue to recommend annual screening mammography starting at age 40. It is important to emphasize that these guidelines apply only to women without symptoms. For any woman who feels a new breast lump, there is universal agreement that a health care provider should evaluate her in a timely fashion. As yet, the USPSTF guidelines have not resulted in insurance coverage changes for mammograms.

A spokesman for the USPSTF, co-chair Michael LeFevre, MD, said the committee reviewed updated and new information, and came to the same conclusion as in 2009: Women ages 60 to 69 derive the greatest benefit from the screening tool in preventing death from breast cancer. While certain women ages 40 to 49 might reduce their risk of dying of breast cancer with regular (annual) mammography, the panel found the benefit much smaller compared to the older age group, leading to too many false-positive tests and unnecessary breast biopsies.

In that age group, a decision to screen should be individual, based on a dialogue between a woman and her healthcare provider, the USPSTF said. However, this would be considered Level C evidence (See “Categories of Recommendations”), meaning insurers would not be obliged to provide coverage.

CATEGORIES OF RECOMMENDATION

The U.S. Preventive Services Task Force uses:
Level A: Good scientific evidence suggests the benefits of the clinical service substantially outweigh the potential risks. Clinicians should discuss the service with eligible patients.
Level B: At least fair scientific evidence suggests that the benefits of the clinical service outweigh the potential risks. Clinicians should discuss the service with eligible patients.
Level C: At least fair scientific evidence suggests that there are benefits provided by the clinical service, but the balance between benefits and risks is too close for making general recommendations. Clinicians need not offer it unless there are individual considerations.
Level D: At least fair scientific evidence suggests the risks of the clinical service outweigh potential benefits. Clinicians should not routinely offer the service to asymptomatic patients.
Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk-versus-benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service.

Controversy.
The USPSTF’s similar 2009 recommendation provoked an uproar, resulting in the U.S. Senate passing legislation that required insurers to cover the procedure for women between ages 40 and 49.

The American College of Radiology (ACR) and Society of Breast Imaging (SBI) in a joint statement said the current recommendation relative to women ages 40 to 49 “would result in thousands of additional and unnecessary breast cancer deaths each year.” The task force reviewed only studies that “underestimate the lifesaving benefit of regular screening and greatly inflate overdiagnosis claims, and ignored more modern studies that have shown much greater benefit.”

Older Women Also Targeted.
Further, the USPSTF found insufficient evidence to make a judgment on the benefits or harms of screening mammography in women 75 and older. Under the recommendation, insurance coverage would not be provided to older women who prefer annual screenings.

The reviewed evidence showed no difference in breast cancer mortality in women age 50 or older who were screened annually versus biennially; nor did the USPSTF review clinical trials that compared shorter and longer screening intervals, according to the ACR/SBI; rather, the trials the task force reviewed had screening intervals of 12 to 33 months.

What It Means.
Adopting these recommendations means that private insurers would no longer have to cover mammography for millions of women, said ACR board chairman Bibb Allen, MD.

The Task Force acknowledged that women with increased breast cancer risk and women who believe in the potential benefits of screening versus the potential harms might benefit from biennial screening starting at age 40.

However, this is considered level C evidence and as such is not covered under the Affordable Care Act, which requires level B evidence or higher to support coverage.

Adjunctive Imaging.
The USPSTF also found “insufficient evidence” to evaluate the potential harms and benefits of other imaging, including breast ultrasound, MRI, and breast tomosynthesis (3-D mammography).

 

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