ACOG’s New Mammogram Recommendations – Not What You Think

The American College of Obstetrics and Gynecology has issued new breast cancer screening guidelines recommending that mammography be offered annually to women beginning at age 40. This is a change from their prior recommendations for mammogram screening every 1-2 years in women ages 40-49, and annually thereafter.

The media is playing the announcement as a face off between ACOG and the United States Preventive Services Task Force (USPSTF), which initially recommended against routine annual mammograms in women in their 40’s, but later softened that statement by saying that the decision to start mammograms in the 40’s should be an individualized one.

But is it really ACOG vs USPSTF? 

Here’s the statement from ACOG’s press release–

Based on the incidence of breast cancer, the sojourn time for breast cancer growth, and the potential for reduction in breast cancer mortality, the College recommends that women aged 40 years and older be offered screening mammography annually.

Here’s that statement in context in from the ACOG practice bulletin (requires paid subscription)-

Based on the incidence of breast cancer, the sojourn time for breast cancer growth, and the potential for reduction in breast cancer mortality, the College recommends that women aged 40 years and older be offered screening mammography annually.

However, as with any screening test, women should be educated on the predictive value of the test and the potential for false-positive results and false-negative results. Women should be informed of the potential for additional imaging or biopsies that may be recommended based on screening results. The physician should work with the patient to determine the best screening strategy based on individual risk and values. In some women, biennial screening may be a more appropriate or acceptable strategy. Some average-risk women may prefer biennial screening, which maintains most of the benefits of screening while minimizing both the frequency of screening and the potential for additional testing, whereas other women prefer annual screening because it maximizes cancer detection.

Hmm…..That’s not really so different from the USPSTF guidelines, which state –

The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.

There is a difference, however. By starting with a statement to offer mammography annually, ACOG seems to be trying take the USPSTF recommendations for individualized screening and put some teeth into them. They are also, I think, aligning themselves with the majority of women, who favor annual screening, regardless of its potential harms. (More on this tomorrow…)

As a clinician, what I think ACOG is saying is that I should be sure I offer an annual mammogram, even if the patient and I end up making an individual decision about having screening that goes another way. It’s a strategy that assures that every woman has the opportunity to have an annual mammogram if that is what she wants, ideally after she has engaged in a discussion that takes into accounts the benefits as well as harms of screening in the context of her own risks, beliefs and concerns.

I think that’s right.

Unfortunately, ACOG’s press release says nothing about individualizing screening decisions

It’s incredible, really.

Just like the USPSTF, ACOG has written a press release and summary statement that does not exactly match it’s recommendations or place them in context. Worse still, they have placed their full recommendations behind a paid subscription firewall, assuring that few folks other than gynecologists will have access to them. This deprives the public (and many reporters and bloggers) of the opportunity to read what is an extremely well-written summary of the current state of knowledge about breast cancer screening.

ACOG has also missed a real opportunity to better inform women about the magnitude of breast cancer risk (much lower than most women think), and the limitations of mammography (much greater than most women think).

Finally, and most importantly, by leaving out any context of individualized risk assessment, benefits and harms of screening, and shared decision making, ACOG has left the simplistic misperception that anything other than an annual mammogram is bad medicine.

And that’s just not fair.

To me, or to my patients.

And, as any women who has tried to fit into a one-size fits all pair of pantyhose will tell you, it’s a set up for failed expectations and anger on all sides.

Not to mention a really bad run.