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Dangers of New ACS Mammography Guidelines: Underestimated Risk and Delayed Diagnoses

The assumption that we can accurately identify who is just at average risk of breast cancer is a dangerous default. Risk is complex, poorly understood, and it's often inconsistently assessed over time.
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The American Cancer Society now recommends cutting back on screening for a large number of American women -- including starting mammogram screening at a later age. The recommendations are for women at "average risk" -- women who are not at higher risk due to known or suspected risk factors that would lead to recommending earlier initiation of screening, shorter intervals, or use of different imaging technology. The intent: to reduce the harms associated with false-positive test results, overdiagnosis, and overtreatment of U.S. women. But risk changes over time and is often underestimated.

The assumption that we can accurately identify who is just at average risk of breast cancer is a dangerous default. Risk is complex, poorly understood, and it's often inconsistently assessed over time.

Here are two examples of how women at higher than average risk could easily be missed by inherent limitations in our healthcare system. Even "validated" genetic risk assessment models can underestimate risk in women with a strong family history. The Gail model, for instance, focuses on the immediate and maternal side of the family history -- excluding the father's side (even though risk is inherited equally from both the mother and father). A second example: A change in a woman's "average" risk may be missed if medical records are not updated to include new cases of breast or related cancers in the family, such as ovarian cancer and melanoma.

Additionally, missed or delayed detection results in aggressive treatments and lives lost. While the harms of unnecessary biopsies and overtreatment are emphasized, the harms of a missed or late diagnosis from dropping both regular mammography and clinical breast exams was largely overlooked by the guidelines. Saving even a few extra lives is worth more regular screening. Plus, other outcomes besides survival are important -- for example, detecting breast cancer early enough to avoid more aggressive treatments such as mastectomy or chemotherapy.

The reality is that every woman is at risk, risk tends to increase over time, and every woman has the ability to modify her risk. It's important to understand and regularly update information about breast cancer risk 0- throughout life -- together with your doctor. To get this dialogue started, here are key points to discuss:

• history of breast or other related cancers affecting a woman and/or her family
• genetic test results for high-risk breast cancer genetic abnormalities
• personal history of receiving radiation therapy to the chest and face before the age of 30
• pathology reports of past breast biopsies, even if they were benign
• being overweight or obese
• current or recent past use of post-menopausal combined hormone replacement therapy (HRT)
• regularly drinking more than three alcoholic beverages per week
• history of being physically inactive
• having dense breast tissue (based on mammogram criteria)
• no full term pregnancy or not breastfeeding
• long history of smoking

Women need to keep their doctors informed about any changes over time; don't assume doctors will ask about them.

Each woman deserves to be given the choice by her medical team: Is she willing to accept the "harm of a false positive" in order to avoid or minimize the very real and devastating harm of missing an early diagnosis of a potentially life-threatening cancer? Personally, I believe most women would choose early detection, since breast cancer remains the most common cancer to affect women in the prime of their lives.

The bottom line is that women need to have an ongoing dialog with their doctors to determine their accurate risk and to identify/share their preferences for their own early detection plan. It's important to have this conversation every year. stands by its recommendation that all women have mammograms annually starting at age 40. If it's determined that a woman is at high risk for breast cancer, she should talk to her doctor about starting annual mammograms at a younger age, and consider including other tools (such as MRI) to maximize the opportunity for early detection.