Screening guidelines vary depending on the age of each woman, and therefore her risk of having breast cancer.

The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).

A	The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.
B	The USPSTF recommends that clinicians provide [this service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.
C	The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D	The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.
I	The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

Women under 40

There are no specific screening recommendations for average risk women under 40. Recommendations for high risk women are addressed later in this module.

Women during their 40s

A controversial topic--some conflicting recommendations.

• Younger women usually have denser breasts, making mammograms more difficult to read, so there are more follow-up studies and biopsies needed.
• USPSTF recommends that women start screening mammograms every 1-2 years at age 40 (level B recommendation).
• The effect of screening mammograms in women in their 40s has been less dramatic than in women over 50.
• Recent meta-analysis showed that screening mammograms in women during their 40s reduced the 15-year mortality from breast cancer by 20%.
• Can be difficult to assess because many women who started screening in their 40s actually were diagnosed with breast cancer after they turned 50.
• Therefore, researchers are not sure if the benefit is due to increased screening in their 40s, or if the cancer could have been discovered with initial screening at age 50.
   
• Women with dense breasts, younger than 50, or perimenopausal may benefit from having a digital rather than a film mammogram, based on preliminary data from a large clinical trial (DMIST) sponsored by the National Cancer Institute (NCI, 2005).

Summary of recommendations for women 40-49 years:

• USPSTF recommends that women start annual or biannual mammograms at age 40 (level B recommendation)--2002
• ACS (annual) and NCI (1-2 years) recommend that women get screening mammograms during their 40s.
• AAFP (2001) and American College of Preventive Medicine (1996) do not recommend mammograms for average risk women in their 40s.

Clinical vignette: Screening a 42 year old woman [3:03] (This link will open in a new window. RealPlayer or Windows Media Player is required.)   Print the Vignette transcript if you would like to read the presentation or follow along while viewing it.

Women between 50-69 of average risk

• annual to biannual mammogram (USPSTF level B recommendation)
• annual clinical breast exam (USPSTF level I recommendation)
• consider regular self breast exam in the context of breast self awareness (USPSTF level I recommendation)
• immediate appointment with primary care provider if any abnormalities are palpated by self exam

Women 70 and older

There is a debate about when to end mammograms. There are only a few studies of the efficacy of mammography among women over 70, and findings are not definitive.

How can we explain this to older women?

• It is easier to detect breast cancer in older women with mammography (because breast tissue is less dense and tumors more noticeable). Yet, we have no data to say that this early detection results in longer survival.
• Tumors in older women are usually slower growing and older women are more likely to have other conditions that could threaten their lives, making the cost-benefit ratio of mammography questionable in older women.
• So, where is the balance of benefit to cost for our older women, those > 70 yrs old?

The cost effectiveness of screening mammograms beyond age 65 - A systematic review for the US Preventive Services Task Force.

The US Preventive Services Task Force completed a meta-analysis of cost effectiveness analysis studies looking at continuing to do screening mammograms in women over 70. Their conclusion was that it was cost effective to continue to perform screening mammograms in women over 70 who do not have any major comorbidities. However, none of the articles reviewed thoroughly evaluated the potential harms of screening. The clinician must make individual recommendations for each woman based on her other medical issues, predicted life expectancy, and health beliefs.

Clinical vignette: Screening for a 78 year old woman [1:38] (This link will open in a new window. RealPlayer or Windows Media Player is required.)   Print the Vignette transcript if you would like to read the presentation or follow along while viewing it.