Breast Cancer Centers Urge Early, Annual Scans, Countering U.S. Guidelines

A panel recommends biennial screenings, starting at 50, but a new study took issue with the way hundreds of centers are telling women 40 and up to come in yearly. Some experts contend that frequent mammograms can “do more harm than good.”

A debate persists over screening frequency for breast cancer — the second leading cause of cancer death for women after lung cancer.
Credit...Njeri Mwangi/Reuters

My last breast cancer screening was “b.c.” — before Covid — just a few weeks before the mysterious new disease was detected in China. The timing was perfect: Everything was normal, and by the time we went into lockdown, my to-do list no longer included a mammogram.

But by November 2020, exactly one year after that scan, I started getting barraged by phone calls and text messages telling me I was due for another one.

“MAMMO MATTERS,” screamed one in all capital letters. “Breast cancer does not take a break during pandemics, and neither should you.” I was well aware that national health guidelines recommend a mammogram only every other year for women at average risk for breast cancer. But there has been a cacophony of advice in recent years as different groups recast their recommendations, often contradicting one another. So the messages were unnerving.

It turns out my imaging center is not alone in badgering women to have mammograms more frequently than the U.S. Preventive Services Task Force deems optimal. A recent study found that hundreds of breast centers tell women who are not at elevated risk of cancer to have a routine scan every year, and to start at 40.

The task force, however, recommends regular mammograms every two years starting at 50. Its guidelines do recommend that women in their 40s discuss mammography with their doctors, evaluate the risks and benefits and come to an individual decision. (The panel’s recommendations extend to age 74; it has said there is not enough evidence to make recommendations past that age.)

The new study, published in JAMA Internal Medicine on March 15, was accompanied by a rather scathing editorial that said extra screening can do “more harm than good.”

“I don’t think breast cancer centers that have clear financial benefits from increasing mammography should be the ones that are giving out patient advice, particularly when it conflicts with the patient’s primary care provider’s advice and the task force’s advice,” said Dr. Rita F. Redberg, editor in chief of JAMA Internal Medicine, who co-wrote the editorial along with Dr. Anand R. Habib and Dr. Deborah Grady.

The American College of Radiology took umbrage, shooting back that it was “outrageous” to assert that breast cancer centers were promoting mammograms for financial reasons, and that the radiologists’ had a different set of guidelines.

When the pandemic started, both routine screenings and appointments triggered by troubling symptoms like the discovery of a lump were delayed as facilities shut down. Even when they reopened, many patients were reluctant to go in.

But Dr. Dana Smetherman, who chairs the American College of Radiology’s breast imaging commission, said the breast centers’ recommendations for more frequent screening predate the pandemic.

“What this study is telling us is that the experts in breast cancer in the U.S. do not support these recommendations,” Dr. Smetherman said in an interview, referring to the U.S. task force’s guidelines.

Indeed: Both the college of radiology and the American Society of Breast Surgeons recommend annual mammograms starting at age 40 (Dr. Redberg’s institution, the University of California, San Francisco, also recommends that schedule).

The American Cancer Society scaled back its recommendations recently, however, endorsing yearly scans starting at age 45, with the option of switching to every other year at age 54. The American College of Obstetricians and Gynecologists recommends women at average risk start mammography at 40, but “every one or two years.”

The debate over screening frequency for breast cancer — the second leading cause of cancer death for women after lung cancer — dates back to 2009. That is when the U.S. Preventive Services Task Force, an independent expert panel that reviews the evidence and provides guidance to doctors and insurers, rolled back its mammography recommendations for women who were deemed at average risk for breast cancer.

Screening can actually be harmful, especially for younger women, the panel found. False positive findings can trigger unnecessary procedures like biopsies, or lead to what experts call over-diagnosis — the aggressive treatment of slow-growing tumors that might never become life-threatening, but cannot be distinguished from fast-growing tumors.

When women had mammograms every other year, the harms of false positives and unnecessary treatment were reduced, the panel determined, while it found the life-saving benefits remained relatively unchanged.

But some experts believe the panel overstated the harms of more frequent screenings. The appropriate schedule for screenings can vary from doctor to doctor, and patient to patient, and has become quite confusing.

“Many women may not even be aware of the guidelines, or that there may be any downside to mammography, and that they have the option to begin screening at age 45 or 50,” Dr. Jennifer L. Marti, an assistant professor of surgery at Weill Cornell Medicine who led the new study, said in an interview. “In almost every other country, women start at 50.”

While many women might assume that “the pros of breast cancer screening outweigh the harms,” Dr. Marti said, that is not always the case for women who aren’t at elevated risk.

Dr. Marti and her co-authors, Mark Lee and Neal Patel, two Weill Cornell researchers, decided to examine the recommendations posted on the websites of some 606 breast cancer centers in the United States. They found that 376 centers — over half — made recommendations that differed from those of the U.S. task force, saying women at average risk for breast cancer should start imaging at age 40.

And 347 centers said women should not only start at 40, but continue annually.

More rigorous screening may be appropriate for some high risk groups, like Ashkenazi Jewish women, who are more likely to carry mutations that put them at risk for breast and ovarian cancer, and Black women, who were likely underrepresented in mammography screening trials, Dr. Marti said.

Women who want help assessing their individual risk to make screening decisions can use an online tool developed by Dr. Margaret Polaneczky, a gynecologist from Weill Cornell Medicine, and Elena Elkin, a research scientist at Memorial Sloan Kettering Cancer Center, Dr. Marti suggested.

As for myself, I’ve been on a two-year plan for a while. I do regular breast self-examinations, and have clinical breast exams too. So even though I felt a smidgen of irrational guilt after receiving the text messages, I politely asked a receptionist to please stop calling. I promised I’d be in touch.