Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society

Abstract

Importance: Breast cancer is a leading cause of premature mortality among US women. Early detection has been shown to be associated with reduced breast cancer morbidity and mortality.

Objective: To update the American Cancer Society (ACS) 2003 breast cancer screening guideline for women at average risk for breast cancer.

Process: The ACS commissioned a systematic evidence review of the breast cancer screening literature to inform the update and a supplemental analysis of mammography registry data to address questions related to the screening interval. Formulation of recommendations was based on the quality of the evidence and judgment (incorporating values and preferences) about the balance of benefits and harms.

Evidence synthesis: Screening mammography in women aged 40 to 69 years is associated with a reduction in breast cancer deaths across a range of study designs, and inferential evidence supports breast cancer screening for women 70 years and older who are in good health. Estimates of the cumulative lifetime risk of false-positive examination results are greater if screening begins at younger ages because of the greater number of mammograms, as well as the higher recall rate in younger women. The quality of the evidence for overdiagnosis is not sufficient to estimate a lifetime risk with confidence. Analysis examining the screening interval demonstrates more favorable tumor characteristics when premenopausal women are screened annually vs biennially. Evidence does not support routine clinical breast examination as a screening method for women at average risk.

Recommendations: The ACS recommends that women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years (strong recommendation). Women aged 45 to 54 years should be screened annually (qualified recommendation). Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually (qualified recommendation). Women should have the opportunity to begin annual screening between the ages of 40 and 44 years (qualified recommendation). Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (qualified recommendation). The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation).

Conclusions and relevance: These updated ACS guidelines provide evidence-based recommendations for breast cancer screening for women at average risk of breast cancer. These recommendations should be considered by physicians and women in discussions about breast cancer screening.

Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosures of Potential Conflicts of Interest. Dr. Etzioni reports stock ownership in Seno Medical Instruments, outside the submitted work. Dr. Flowers reports having received compensation as a consultant to Spectrum, Celgene, Optum Rx, and Seattle Genetics, serving as an unpaid consultant to Genentech/Biogen-Idec/Roche and Millenium/Takeda, and receiving compensation for development of educational presentations from Clinical Care Options, Educational Concepts, PRIME Oncology, and Research to Practice. His institution has received research funding from Abbvie, Acerta, Celgene, Gilead Sciences, Infinity Pharmaceuticals, Janssen Pharmaceutical, Millenium/Takeda, Spectrum, Onyx Pharmaceuticals, and Pharmacyclics. Dr. Michaelson reports having received compensation from NA for consulting on lawsuits involving the treatment of cancer and having received grant funding from Nikon. Dr. Smith reports serving as an unpaid advisor on General Electric Health Care’s Breast Medical Advisory Board, to provide advice on appropriate implementation of technology in low- and middle-income countries. The other authors report no disclosures.

Figures

Figure 1. Breast cancer burden by age at diagnosis, 2007–2011

Panel A. Age distribution of invasive female breast cancer cases (n=292,369), 2007–2011. Source: SEER 18 registries. Panel B. Distribution of breast cancer deaths by age at diagnosis (n=16,789), with patients followed for 20 years after diagnosis, 2007–2011. Source: SEER 9 registries. Panel C. Distribution of person years of life lost due to breast cancer by age at diagnosis (Total= 326,560), with patients followed for 20 years after diagnosis, 2007–2011. Source: SEER 9 registries. The YPLL is based on the 2011 US female life table.

Figure 2. Upper, Middle, and Lower Quartiles of Life Expectancy for Women at Selected Ages

Adapted from from Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA, 2001; 285:2750–2756; using 2010 United States Life Tables.