BREAST CANCER: 2015

In case you missed it, October was National Breast Cancer Awareness month, and there were at least two important events:

The first was a wonderful WHEP seminar by “Living Beyond Breast Cancer” including a very impactful panel discussion with four survivors,

and the second was a change in the American Cancer Society (ACS) guidelines for mammography screening (published October 20, 2015 in the Journal of the American Medical Association).

A little history...

In 2003, the ACS recommended annual mammograms for all women starting at age 40 and continuing as long as a woman remained in good health, and clinical breast examination periodically for women in their 20s and 30s and annually for women 40 years and older.

Contrast that with the new recommendations:

Women with an “average risk” of breast cancer – (i.e. most women) – should begin yearly mammograms at age 45.  However, the ACS also states that women should be able to start the screening as early as age 40, if they want to.  We know that about 12% of women in the general population will develop breast cancer sometime during their lives.  For women in their 40s and 50s, randomized trials have shown that screening mammography modestly decreases breast cancer mortality by approximately 15%.

• At age 55, women should have mammograms every other year – though, again, women who prefer to continue yearly mammograms may do so.
• Regular mammograms should continue for as long as a woman is in good health.
• Breast exams, either from a medical provider or self-exams, are no longer recommended.  Still, the ACS says all women should be familiar with how their breasts normally look and feel and report any changes to their health care provider right away.

These guidelines do not pertain to women at “high risk” due to family history, a breast condition, or other reason.  Clearly, women who are BRCA 1 or 2 positive are at high risk for breast cancer as are those with a strong family history (multiple relatives with breast cancer).  But how should we think about risk when breast cancer has occurred in a single first degree relative knowing that women with a "family history" of breast cancer make up only 5 to 7 percent of all women with breast cancer?

Bottom line: the ACS guidelines recommend that screening decisions be individualized to reflect a woman’s values and preferences, as well as her underlying risk of breast cancer.  Is this a “hedge” or a move toward more personalized medicine?

                                                                                                                         Judith Wolf, MD   Associate Director, WHEP