INDIVIDUALIZE BREAST CANCER SCREENING

New breast cancer screening guidance from the American College of Obstetricians and Gynecologists (ACOG) highlights the importance of shared decision-making between the patient and provider.

The practice bulletin, published in the July issue of Obstetrics & Gynecology, focuses on women at average risk for breast cancer. The authors acknowledge the existing confusion from disagreement among major guidelines on when to start screening mammograms and how often to have them.

"Our new guidance considers each individual patient and her values," Christopher M. Zahn, MD, ACOG vice president of practice activities, said in a press release. "Given the range of current recommendations, we have moved toward encouraging obstetrician–gynecologists to help their patients make personal screening choices from a range of reasonable options."

The decisions of when to start and end screening and how often to have it should follow discussions of the woman's health history and her concerns and preferences surrounding the potential harms and benefits of the screening.

The practice bulletin, which was developed by the Committee on Practice Bulletins–Gynecology in collaboration with Mark Pearlman, MD; Myrlene Jeudy, MD; and David Chelmow, MD, also says that women at average risk for breast cancer should be offered screening mammograms starting at 40 years of age and should start no later than age 50 years.

This differs from some other major guidelines. The US Preventive Services Task Force, for instance, recommends mammograms start at age 50 years. At ages 40 to 49 years, the decision should be made individually, the task force says. The American Cancer Society says screening should be offered at 40 years, but recommends starting at age 45 years.

Regarding frequency, average-risk women should have screening mammograms every 1 to 2 years and should continue to have them until age 75 years, ACOG says. After that, the choice to continue should be based on shared decision-making that takes into account women's health status and expected lifespan.

Among the B-level recommendations, based on limited or inconsistent scientific evidence, the updated guidelines say providers should assess breast cancer risk periodically by reviewing the patient's history.

"Initial assessment should elicit information about reproductive risk factors, results of prior biopsies, ionizing radiation exposure, and family history of cancer," they write.

In addition, breast self-exams are not recommended in average-risk women because of the risk for harm from false-positive results and lack of evidence it benefits patients.

Instead, average-risk women should be counseled about breast self-awareness, or the normal look and feel of her breasts. So rather than routinely examining their own breasts, the women should be educated on noticing pain, a mass, new nipple discharge, or redness, and then telling their physicians if these signs occur.

The bulletin did not address recommendations for women at high risk for breast cancer or use of new technologies such as tomosynthesis. It also did not offer advice for women with dense breasts, who have a modestly increased risk for breast cancer.

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2017;130:e1-e16. Abstract