Clearing up the breast screening quagmire

The American Cancer Society releases new, more flexible guidelines. Here's what you need to know
Woman and her doctor
The American Cancer Society issued new breast screening guidelines that Fred Hutch experts call much more flexible. "Screening is shifting away from a one-size-fits-all approach," said Dr. Janie Lee, director of the breast imaging clinical service at Seattle Cancer Care Alliance. File photo by Emmanuel Rogue / MediaforMedical via Getty Images

It’s that time again.

The American Cancer Society has just released a new set of breast screening guidelines, recommendations that are usually greeted with as much enthusiasm – and confusion – as a new tax code.

The guidelines, last updated in 2003, were published Tuesday in JAMA.  Overall, they reflect a shifting attitude towards mammography, with a handful of changes designed to better balance the procedure’s benefits with its harms, including a recommendation to start screening five years later, at age 45.

Dr. Ruth Etzioni, a biostatistician with Fred Hutchinson Cancer Research Center and a member of the ACS guidelines committee, said the new guidelines are, overall, more sensitive to the “cumulative burden of testing.”

“The important take home of the new ACS guidelines is that while retaining the focus on reducing deaths from breast cancer, the guidelines reflect greater sensitivity to the burden of testing and potential adverse outcomes of screening,” she said. “Women are getting exposed to a lot of testing; a lot of false positives; a lot of unnecessary biopsies cumulatively over their lifetime. And the younger you start, the greater that cumulative burden.

“I think the ACS wants to make sure that women have access to screening and also wants to be sensitive to the cumulative burden of screening,” she said. “Consequently, the new guidelines are more flexible than the guidelines have traditionally been.”

Fred Hutch News Service sat down with Etzioni and other researchers at Fred Hutch and its treatment arm, Seattle Cancer Care Alliance, to parse the changes, understand why they were made and answer your crucial breast screening questions.  

Dr. Ruth Etzioni
Fred Hutch public health researcher Dr. Ruth Etzioni, who helped create the new guidelines, said they are more sensitive to the "cumulative burden of testing." Photo by Robert Hood / Fred Hutch News Service

What are the new guidelines?

The old ACS guidelines recommended women start getting annual mammograms at age 40; the new ones bump that up to age 45. Women ages 45 to 54 should be screened once a year, they say, with women over 55 going in for a mammogram every other year.

But there’s a lot of wiggle room on those last recommendations.

If you want to start screening at age 40, feel free to do so. And if you’re over 55 and want to keep getting annual instead of biannual mammograms, that’s okay, too.

“Screening is shifting away from a one-size-fits-all approach where every woman gets an annual mammogram starting at age 40,” said Dr. Janie Lee, director of the breast imaging clinical service at Seattle Cancer Care Alliance.

Screening mammography reduces a woman’s chance of dying of breast cancer by catching it earlier, before a breast lump can be felt. But because the chance of having cancer increases with age, younger women have fewer breast cancers and a higher chance of having a false-alarm with screening. These false alarms can result in having additional mammography or ultrasound tests, or a biopsy with results that are benign (not cancer). Some women may even be diagnosed with a very low-risk cancer that is treated with surgery or chemotherapy, even though it may not have ultimately caused a breast cancer death.  

Balancing the known benefits and potential harms of screening is likely to mean different screening choices for different women, said Lee.

Some women may want to start screening at 40 – and to screen every year, even after 55 – because detecting breast cancer as early as possible outweighs the risk of having a false-alarm. Others will choose to wait until they’re 45 to screen and screen every other year after 55.

"For women who choose screening every other year, the chance of reducing their risk of breast cancer death is still high, and the chance of false-alarms is reduced by a much greater amount," she said. 

Lee said the guidelines are important because “at the individual level, [we’ll] have choices that better match women’s values. And at a population level, we’ll do a better job of maximizing health.”

As for how long screening needs to go on, the new ACS guidelines say that women should continue to get mammograms as long as their overall health is good and they have a life expectancy of 10 years or longer, similar to previous recommendations.

And there’s one more big change: clinical breast exams (CBEs), where doctors check for lumps and such, have been given the boot.

While previous guidelines endorsed the use of CBEs for women in their 20s, 30s, and 40s, the American Cancer Society no longer recommends them for average-risk asymptomatic women of any age.

Instead, they say doctors should use this time to ascertain family history, counsel women about what breast changes they should watch out for and talk with them about the benefits, limitations and potential harms of mammography.

Dr. Janie Lee
The changing guidelines "are not meant to confuse but rather to empower patients,” said Dr. Janie Lee, director of breast imaging clinical service at Seattle Cancer Care Alliance. “[They're] more of an acknowledgement that experiences vary." Photo courtesy of Seattle Cancer Care Alliance

Why so many guidelines and why are they always changing?

“It’s very confusing for the public,” said Etzioni, acknowledging the various, and sometimes conflicting, guidelines issued by the American Cancer Society, the U.S. Preventive Services Task Force (USPSTF), the American College of Radiology, the Society for Breast Imagers, etc. “But usually when people cite guidelines for screening, they’ll cite the Task Force and they’ll cite the ACS.”

What’s the difference between the two?

Etzioni said the USPSTF is predominantly made up of primary care doctors and, thus, is concerned with the whole, healthy population. The American Cancer Society, on the other hand, is all about reducing death from cancer so their guidelines have traditionally been more rigorous.

“These new ACS guidelines are actually a lot closer to the Task Force guidelines than the old ones,” Etzioni said. “There is now more of a consensus between the two main guidelines than ever before. This should make women feel less confused and more confident.”

As for why the guidelines keep shifting and changing, Lee said it’s all about the science.

“Guidelines change in part because information changes,” she said.  

But the new ACS guidelines also reflect a shift towards more patient-centered, evidenced-based care.

“These changing guidelines are not meant to confuse but rather to empower patients,” she said. “[They're] more of an acknowledgement that experiences vary. For some but not all women, having a false alarm is really anxiety-producing.”

Etzioni emphasized that they are simply guidelines, not directives set in stone.

“The guidelines are really giving women more flexibility,” she said. “Rather than saying they need to come at 45, we’re saying we don’t need to be religious about [coming in at] 40. They can come a bit later; 45 is a guide. They can even come in at 50 if they want.”

These guidelines are for average risk women. What’s “average risk” and “high risk”?

According to the American Cancer Society, you are at average risk if you do not have a personal history of breast cancer, a confirmed or suspected genetic mutation that could bump your risk such as BRCA1/BRCA2,  or a history of radiation to the chest (for instance, if you were a pediatric or young adult cancer survivor).

High risk women have one or more of these risk factors and should talk to their doctor and follow the screening guidelines designed for them. 

What about “intermediate risk” women?

Some women have an intermediate or increased risk and may want to look into additional screening, according to the ACS. These women include those with a family history of cancer but who don’t carry a BRCA or other recognized mutation; those with a prior diagnosis of benign proliferative breast disease (such as ductal or lobular hyperplasia) and women with dense breasts.

The American Cancer Society said it plans to review additional evidence and update its screening recommendations for women at increased and high risk in days to come. If you have a question about your individual risk and the type of screening you need, talk to your doctor and/or contact the SCCA’s Reduce Your Risk Clinic.

What about dense breasts?

Dense breasts are problematic for two reasons: women with very dense breasts have a higher risk of breast cancer (similar to having a mother or sister with the disease) and dense breast tissue may also mask breast cancer, making it more difficult to detect: cancer becomes the polar bear in a snowstorm. 

The new guidelines acknowledge that dense breasts may put women at an intermediate risk for breast cancer and but don’t provide any screening recommendations at this time. That, they said, will come when they finish reviewing evidence.

Etzioni, however, said the dense breast tissue issue is one reason the ACS recommends screening younger women more often than older women: dense breasts are more prevalent in younger women.

“As you get older, the breasts are less dense and become fattier,” she said. “So you can go two years because you’re more likely to catch an existing tumor with one screen whereas in a young woman, you might do better with two chances.”

And Lee said improved technology has made dense breasts easier to read.

“We’re very excited about digital breast tomosynthesis, sometimes called 3-D mammography,” she said. “It reduces the false positives from screening and it may also detect additional cancers that might not be seen with digital mammography alone."

Are mammograms moot at this point?

Not at all. While the new ACS guidelines step back from mammography a bit, they also emphasize their overall value, referring to the “weight of the evidence” that mammograms reduce breast cancer deaths.

“Everyone is consistent in their recommendation for the support of mammography and regular mammography,” said Lee regarding this point. “The evidence is clear that mammography saves lives.”

Etzioni, who recently looked at the value of mammograms in the context of newer, more effective cancer treatments, agreed.

“The evidence is still valid,” she said. “Screening absolutely still works.”

What do you think of the new guidelines? Tell us about it on Facebook.

Solid tumors, such as those of the breast, are the focus of Solid Tumor Translational Research, a network comprised of Fred Hutchinson Cancer Research Center, UW Medicine and Seattle Cancer Care Alliance. STTR is bridging laboratory sciences and patient care to provide the most precise treatment options for patients with solid tumor cancers.

Diane Mapes is a staff writer at Fred Hutchinson Cancer Research Center. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor, she also writes the breast cancer blog Reach her at

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