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American Cancer Society Responds. to

Changes to USPSTF Mammography
Guidelines
The American Cancer Society guidelines will not change; annual

mammography recommended for women 40 and over

Atlanta 2009/11/16 -November 16, 2009-The UnitedStates Preventive

Services Task Force (USPSTF) today announced that it is changing its
guidelines for mammography and no longer recommends routine.
screening for women between the ages of 40 and49. Below is a
statement from Otis W. Brawley, M.D., chief medical officer, American
Cancer Society.

''The American Cancer Society continues to recommend annual screening

using mammography and clinical breast examination for all women
beginning at age 40. Our experts make this recommendation having
reviewed virtually all the same data reviewed by the USPSTF. but also
additional data that the USPSTF did not consider. Vllhen
recommendations are based on judgments about the balance of risks and
benefits. reasonable experts can look at the same data and reach different
conclusions.

"In 2003. an expert panel convened by the American Cancer Society

conducted an extensive review of the data available at the time. ,which
was not substantially different from the data included in the current
USPSTF review. Like the USPSTF, the Society'spanel found convincing
evidence that screening with mammography reduces breast cancer
mortality in women ages 40-74, with age-specific benefits varying.
depending on the results of i:1dividuai trials and which trials were
combined in meta-analyses. And like the USPSTF, the American Cancer
Soder! panel also found that mammography has limitations - some
women who are screened will have false alarms; some cancers will be
missed; and some women will undergo unnecessary treatment. These
limitations are somewhat greater in women in their forties compared with
women in their fifties, and somewhat greater in women in their fifties
compared with women in their sixties. We speCifically noted that the
overaH effectiveness of mammography increases with increasing age. But
the Iimitatio:'1s do not change the fact that breast cancer screening using
mammography starting at age 40 saves lives. "As someone who has long
been a critic of those overstating the benefits of screening, I use these
words advisedly: this is one screening test I recommend unequivocally,
and would recommend to any woman 40 and over, be she a patient. a
stranger, or a family member.

UThe USPSTF says that screening 1,339 women in their 50s to save one
life makes scree:'1ing worthwhile in that age group. Yet USPSTF also says
screening 1,904 women ages 40 to 49 in order to save one life is not
 ACS :: American Cancer Society Responds to Changes to USPSTF Mammography Guide ... Page 2 ?f3 ,

worthwhile. The American Cancer Society feels that in both cases, the

lifesaving benefits of screening outweigh any potential harms. Surveys of

women show that they are aware of these limitations. and also place high

value on detecting breast cancer early.

"With its new recommendations, the USPSTF is essentially telling women

that mammography at age 40 to 49 saves lives; just not enough of them.

The task force says screening women in their 40s would reduce their risk

of death from breast cancer by 15 percent, just as it does for women in

their 50s. But because women in their 40s are at lower risk of the disease

than women 50 and above, the USPSTF says the actual number of lives

saved is not enough to recommend widespread screening. The most

recent data show us that approximately 17 percent of breast cancer

deaths occurred in women who were diagnosed in their 40s, and 22

percent occurred in women diagnosed in their 50s. Breast cancer is a

serious health problem facing adult women, and mammography is part of

our solution beginning at age 40 for average risk women.

''The American Cancer Society acknowledges the limitations of

mammography, and we remain committed to finding better tests, and
currently are funding a large study to improve the accuracy of
mammography. In fact, data show the technology used today is better
than that used in the studies in this review, and more modern studies
show that mammography is achieving better results than those achieved
in these early experimental studies that go back as far as the mid-60's.
And as scientists work to make mammography even more effective, the
American Cancer Society's medical staff and volunteer experts
overwhelmingly believe the benefits of screening women aged 40 to 49
outweigh its limitations."

The American Cancer Society combines an unyielding passion with nearly

a century of experience to save lives and end suffering from cancer. As a
global grassroots force of more than three million volunteers, we fight for
every birthday threatened by every cancer in every community. We save
lives by helping people stay well by preventing cancer or detecting it early;
helping people get well by being there for them during and after a cancer
diagnosis; by finding cures through investment in ground breaking
discovery; and by fighting back by rallying lawmakers to pass laws to
defeat cancer and by rallying communities worldwide to join the fight. As
the nation's largest non-governmental investor in cancer research,
contributing about $3.4 billion, we turn what we know about cancer into
what we do. As a result, more than 11 million people in America who have
had cancer and countless more who have avoided it will be celebrating
birthdays this year. To learn more about us or to get help. call us anytime,
day or night, at 1-800-227-2345 or visit cancer.org.

###

http://wv....w.cancer.org!docroot/MEDicontentJMED_2_) x_Amcrican_Cancer_Society_Resp... 3/2/2010

 r . . . .,
L,'LH-.rICAL GlIIDFLINES
Screening for Breast Cancer: U.S'. Preventive Services Task Force
Recommendation Statement
u.s. Preventive Services Task Force"
!)escription: Update of the 2002 U.S. Preventive Servi:es Ta>k
Force (USPSTf) recommendation statement on screening for breast
cancer in the general populatiOJ:l.
Methods: The USPSTF examined the evidence on the efficacy of 5
screening modalities in reducing mortality from breast cancer: film
mammography, dinical breast exaJnination, breast setf-exarnination,
digital mammography, and magnetic resonance imaging in order to
wpdate the 2002 recommendation. To accomplish this update, the
USPSTF commissioned 2 studies: 1) a targeted systematic: evidence.
review of 6 selected questions relating to benefits and harrns of
screening. and 2) a decision analysis that used population
modeling techniques to compare the expected health out
comes and res:;Jurce requirements of starting and ending
mammography screening at different ages and using annual
versus biennial screening intervals.
Recommenci;:.tions: The USPSTF recommends against routine
screening mammography in women aged 40 to 49 years. The
decision to start regular, biennial screening ma:nmog~aphy before
the age of 50 years should be an individual one and take into
account patient context, including the patient's values regarding
specific benefits and ha.'Tns. (Grade C recommendation)
Tht U.S. h(vmtivt Sm!iw Task Fora (USPSTF)
I m/:dus rtcommmdatjorIJ abow prromtivt carf srrvices
for jJl1timt! without ruogni:ud signs or symptoms of rhr
rargft condition. . but individwzbu dtcisitm making tc the spuific ptltimt or
It basu it! rccommmdtZtions on a -')'It/matic re'Jiew of fht
roidmu ofthf bmtifits and hanm and an 4!SfJ.rmmr of fiu lut
bmfjit of tht str'"ict.
See a/50:
Print
Editorial comment ................. _ .... : ..' 750
Related articles ................... , 703, 727; 738
Summary for Patients.. : ...... , ............. 1-.44
Wef?-pnly
mography for women aged 50 to 74 years. This is a B
,A,ppej,dil!(
recommendation.
Cfl\E quiz -- .
. Conversion of graphJc:s into slides
insufficient to assess the additional benefits a."ld hums of
Downloadab'e rec6mm~ndatio:1 summary
screeni."1g mammography in women 75 years or older. THs
I
716/17 November l0091,:.nn.J., "f In:""",: M<:didn, Volume 151 Nomb", 10
The USPSTF recommends biennial screening mammography
for women between the ages of 50 and 74 years. (Grade 3
recom mend ation)
The USPSTF condudes that the current evidence Is ln5uffident to
assess t'le additlonaf benefits and harms of screening nammogra
phy in women 75 years or older. (1 statement)
The USPSTF concludes that the current evidence is jr!S:.lifieient to
a>s~ the additional benefits and harms of dinical breast examina
tbn beyond screening ma.'ilmography in womer. 40 years or oider.
(I statement)
The USPSTF recommends against clinicians teaching women how
to perform breast self-examination. (Grade D recommendation)
The U5PSTF condudes that the current evidence is insufficient to
assess additionaJ benefits and harrns of either digr-..al marnr.lography
or magnetic resona.'1ce imaging instead of film mammography as
screening modalities for breast cancer. (I statement)
Ann Intem Meet. 2009;151;716-726.
For author affiliation, see end of text
For a list of the membe!:S of th: U5PSTF, see the Ap?endix (available at
wvJW.anna.!s.org).
Tht USPSTF rtcognias that clinical or policy tkcisiorJ
involvf mOl( considmltiorJ t.han this body cf roi:/n,.C( aionf.
Clinicians and poliC;'maluTJ should undmt:md thr evidmu
sir-.uztio n.
SUMMARY OF RECOMIv',ENDATIONS A!~D EViDENCE
The USPSTF recommends against rourine screening
m;unmogra.phy in women :lged 40 to 49 years. The deci
siOl1 to Start regular, biennial screening mammography be
fore the age of 50 years should be an individu:tl one and
take patient conrexr into account, inciudi"lg the patient's
values reg-...rding sp!:cinc bendits and harms. This is a C
recommendation.
The USPSTF recommends biennial screenir.g m2I'.l
The USPSTF concludt:S that the current e,,"iCence is
is an I statement.

The USPSTF recommend, against teaching breast
stlf-examination (ESE). This is a D recommendation.
The USPSTF conch.:des that the current evidence is in
;ufficicnr [Q d.'ise:;s the addilional benefit.> and harms of clinical
hrc:m examination reEE) beyond s.:-reening mammography
ill women 40 years or older. This is an I statement.
The USPSTf concludes that the current evidence is
insuf'hcier:t to asses:; the additiollal benefits and harm:; or
either digital mammography or magnetic resonance imag
in~ (MRl) instead or film mammography a, screenint!, mo
dalities for breast cancer. This is an I statement.
Figures 1 a.nd 2 summarize the recommendations and
provide suggesrions for clinical practice.
Table 1 describes the USPSTf grades and Table 2
describes the USPSTF classiilcarion of levels of cen:linry
about net benefir.
See Clinical Considerarions for specific popularions at
incrca;,ed risk and for suggestions f1Jr practice regarding the
1 statements.
Importance
Breast cancer is [he second-leading cause of cancer
death among women in rhe United States. \XTidesprcad use
of scrcl:ning, along with treatment advances in recent years,
have bem credi:ed wich significant reducrions in breast
cancer morrality.
Detection
i\1ammography, a..s well as physical examination of the
breasts (CBE ar.d ESE), can decen presymptomatic breast
cancer. Because of its demonstrated effectiveness in ran
ciomi7,ed, comrolled trials of screening, film mammogra
phy is the standard for detecting breast cancer; in 2002, the
USPSTF found convincing evidence of irs adequate sensi
civic}' and ;pt'cif:ciry.
Benefits of Detection and Early Intervention
There is cOllvincir.g evidence thar screening with film
mammography reduces breast cancer mortality, with a
greater absolure reduction for women aged 50 to 74 years
than For women aged 40 to 49 years. The strongest evi
del ICe for rhe greatest benefit is among women aged GO ro
69 years.
Among women 75 years or older, evidence of benefits
of mammography is Jacking.
Adequate evidence suggem that reaching ESE does
not reduce breasr cancer morraliry.
The evidence for additional effects of CBE beyond
r:1ammography on breast cancer morrality is inadequate.
The evidence for benefits of digital mammography
.1:d :\1R! of dle brca~t, as a mbsr:tutc for iilm mamm0f,
taplly, is also lacking.
Harms of Detection and Early Intervention
The harms resultir.g from screening for breast cancer
include psychological harms, unnecessary imaging rc:sts and
,\L GUll}l1 !K1S
biopsies in women wirhour cancer, and inconvenience due
to false-positive screening results. Furthermore, one must
also consider the harms associated with treatment of cancer
that would not become clinicaJJy apparent during a wom
an's lifetime (o\'etdiagnosis), as well as the harms of unnec
essary earlier rreatmt'nt of breast cancer that would have
become clinically apparent but would nor have shortened a
woman's life. Radiation exposure (from radiologic tests),
although a minor concern, is also a consideration.
Adequate evidence suggests that the overall harms as
sociated with mammography are moderate for every' age
group considered, although the main components of the
harms shife over rime. Although false-positive test results,
overdiagnosis, and unnecessary earlier treatment are prob
lems for all age groups, [llse-posirive results are more com
mon for women aged 40 to 49 years, whereas overdiagnosis
is a greater concern for women in the older age groups.
There is adequate evidence that reacl1ing BSE is asso
ciated with harms that are at least small. There is inade
quate evidence concerning harms of CEE.
USPSTF Assessment
The USPSTF has reached the following conclusions:
For biennial screening mammography in women aged
40 to 49 years, there is moderate certainty that cile net
benefit i, small. Ahhough the USPSTF recognizes that the
benefit of screening seems equivalent for women aged 40
to 49 years and 50 to 59 years, the incidence: of breast
cancer and the consequences differ. The USPSTF empha'
sizes the adverse consequences for most women-who will
not develop breast cancer-and rherefore use the number
needed (Q screen (Q save 1 life as irs metric. By this metric,
the USPSTF concludes that there is moderate evidence
that the net benefit is small for women aged 40 ro 49 years.
For biennial screening mammography in women aged
50 ro 74 years. there is moderate cenain)' that the net
benefir is moderate.
For screening mammography in women 75 years or
older, evidence is lacking and rhe balance of bench ts and
h(lrms cannot be determined.
For the teaching of BSE, rhere is moderate certainty
that the harms outweigh the benefits.
For CBE as a supplement to mammography, evidence
is lacking and the balance of benefits and harms cannor be
determined.
for digital mammography and MRl as a replacement
for mammography, the e\ridence is lacking and the balance
of benefits and harms cannor be determined.
CWHeAL CONSlDERAT!or~S
Patient Population Under Consideration
This recommendation statement applies to women 40
y[:ars or older who :ire nor at increased risk for breast can
cer by virtue of a known underlying genetic mutation or a
hisrory of chest r;;.ciiarion.
 Assessment of Risk
Increasing age is the most important risk faeror for
breast cancer for most women. Women wiiliout known
deleterious genetic mutations (such as BRC-41 or BRO.2)
may still have oilier de.o.ographic, physical, or hisrorical
risk factors for breast cancer, but none conveys a clinically
important absolute increased risk for cancer.
Screening Tests
In recent decades, the early detection of breast cancer
has been accomplished by physical examin.ation by a clini
cia.n (CBE), by a woman herself (BSE), or by ma.tnmogra
ph)'. Standardization of mammography practices enacted
by the Mammography Quality Standards Act have led to
improved ma,:nmography quality. Clinicia."lS should refer
patients ro Mammography Quality Stan.dards Act-cerrid
facilities, a listing of which is available at \vwvvJda.gov
Icdrb!ma..rnmography/cerrified.html.
Screening Intervals
In trials dut dem.onstrated the effectiveness of mam
mography in decreasing breast cancer monaliry, scree.wg
was performed every 12 to 33 months. The evidence re
viev...ed by the USPSTF indicates that a large propomon of
the beneiic of screening mammography is maintained by
bier.nial screening; and cha.!"lging from ar...nual to biennial
screening is likely to reduce the harms of mammography
screening by nearly half. At the same rime, beneht may be
reduced when e..:tendlo:g the interval b~'ond 24 months;
therefore the USPSTF recommends biennial screening.
Treatment
Effective treatmems, including radiacion, chemother
apy (inclurur:g hormonal treatment), and surgery, :lIe avail
able for invasive carcinoma. Although tIle standard treat
mencs women receive for ductal carcinoma in sim (DCIS)
include surgical approaches as weU as radiation ,Uld hor
monal therapy, considerable debate exists about the opti
mal treatment strategy for this condition.
Considerations for Practice Regarding I Statements
Clinical Breast Examination
Pour-tial Prevmtable Burdm. The evidence for CSE,
although indirect, suggeStS that CBE may detect a substan
tial proportion of cases of canc.er if it is the o:Jy screening
test available. 1r1 parts of the world where mammography is
infeasible or unavailable (such as India), CBE is being
investigated in this VI"ay.
Potential Harms. The potencial harms of CBE are
u':!ought to be smill but include filie-positive test results,
which lead to anxiety and breast cancer worry, as well.as
repeated visits and unwarraIlted imagi..t"lg and biopsies.
Com. The principal cost of CBE is the oppOrtur.ity
cost incurrd by cli..'1icians i.'l the patient enCoULter.
Cumr.! PrlUtice. Surveys suggest (l) that the CBE
techl'ique used in the United States currently laoo a W ...!l
dardapproach and reporting srancards. Clinic:ar:.s who are
committed to spending the time on CBE would benefit
718 rli Ne,,,mber 2009 Ir""d, af!ne",""", '.{odicit;, jVolume 151' Numb'l lC
meir patients by considering the evidence in favor of a
Structured, standardized examination (2).
Digital A1ammography
Potential Prevtnt4.bfr Burden. Digital ma..'T..mography
derecrs some cases of cancer nor identified by film mam
mography; film mammography detec-..s some ca.se.s of can
cer not identified by digital mammography. Overail dmc
tion is similar for many women. For wo~en who are
younger than 50 years or have dense breast tissue, overall
derection is somevvnat higher wirh digital mammography.
It is not clear whether this addicional detection would lead
to reduced mortality from brea.st cancer.
Potential Harms. The possibiliry of false-positive test
resufrs is similar for Elm a.."ld digital mA..'n.rnography. 1t is
uncer-..ain whether overd1a"GIlosis occurs more wrt:.1:! digital
mammography than wit.1:! film mammography.
COltS. Digital mam.-nography is more expe.ruive than
Elm mammography.
. Current Practice. Some clinical practices are now
switching. thcir mammography equipment from file to
digital. This may cunail the availability of Elm mammog
raphy in some areas.
Magnetir:: Resonance Imaging
Potmtial Pl'lvmtabk Burdm. Studies of the use of
contr.lSt-enhanced l\oo for breast canca: screening bye
been conducted orJy in very high-risk populacions .. In
these smdies, MR1 detec.:ed more cases of cancer man did
man::mograpby. It is unknown ",-hether detecting t..~ese ad
ditional cases of cancer would lead to redued breast cancer
monallty.
Pounti~i Harms. Contr-..st-enhanced MRI :eqcires t..l:le
injeccion of contrast material. Studies of MRI screening
have shov.'n that MRI yields many more false-positive re
sdts than does ma.mmography. Magnetic resonance imag
ing has the potential to be associated wit.~ a gr::ater degree
of overdiagnosis t..~an ma:m.rcography.
COlt!. Magnetic resonance imaging is much more ex
pensive u~an cirher film or digital ma..'TImogrnphy.
Current Practice. l\,14gnetic resona.."1.ce imaging is not
currently used for screening women at average risk for
breast cancer.
5creening Mammography in Women 75 Years or Older
Pountid Prromtabfr Burden. No women 75 years or
old.er have been included in tb.e multiple randomized clin
ical trials of br::ast cancer screening. Breast cancer is a lead
ing cause of death in older women, ,vhich rnight suggest
that the benefits of screen.i..."lg could be i:nportant at t:.llls
age. However, 3 facts su.ggesr that benefits from screening
would probably be smaller for this age group ::han for
women aged 60 to 69 years and probably deCrease with
increasing age:: 1) the benefics of screening occu.r only sev
eral years mer uie actual screening test, whereas the per-
v,ww.annals.or
 Cf'nr;lE,C of women "dlO SUITive IO:1g enough to benciit de
creases with age; 2) a higher percentage of the eype of
breasl cancer detected in this age group is the more easily
treated estrogen n;:cepror-posirivc type; and 3) wumen of
1his age are at much greater risk for dying of other cOI!di
(ions that wodd not be affected by breast cancer screening.
Porenri,1! Harms. Screening detects not only cancer
that could lead to a woman's death but also cancer that will
lint shonell a \NOman's life. \X'omeJJ cannot bellefit from
SUl can be harmed hv-the , , and treatment of this
disClwerv
second type of cancer, which includes both cancer lhat
might some become clinically app;!reIH and cancer that
cever will. Detection of cancer that \vould never han: be
come clinically apparent is called ()Z'erdi,tgnosis, and It is
L:slIally followed by OVl;'flrearmenL Bt:causc: of a shortened
life span among women 75 years or older, the probability
o~ overdiagnosis and unnecessary earlier rrcaunem in
creases dramatically after abom age 70 or 75 years. Over
diagnosis and unnecessary earlier treatment arc importa11l
potential harms from screening women in this age group.
Currellt Pra(fict. Studies show char many women 75
rears or older ar(;' currently bt"ing screcntd.
Useful Resources
Other USPSTF recommendarions on screening for ge
netic susceptibility for breasr cancer and chcmoprevenrion
of breast cancer are available on the Agellc}' for Healtheare
Research and Quality \Veb site (w\\"w.prevemlveser\,ices
.ahrq.goyl.
OTHER (ONSiDERATiONS
Implementation
The Task Force on Community Preventive Sef\'ices
h::s reviewed the evidence on methods to increase breast
cancer including reminder systems and ocher in-
Explanation of Change in Recommendation
The 2002 USPSTF issued a B recommendation for
screening mammography tor women 40 years or older.
However, it went on [Q say:
The precise age at wbich the hme5:5 from SCI ecning
marnmogr;;pl1y jU5tifl' the ?Drcnriai harms is a subjec
tive and should take inca account patient
preference,. Ciniciam ,hould infol:n women ;:.bout UiC
potencial benefits (reduced chance Hf dying fwm brcasr
cancer), potential harms ([or exampl::, re
suhs, unrH:cessary hiopsies), 2nd limitations of the test
th:n ~P?:Y to women their age. Clinici"ns should teI!
women tb.t the bal~nce of benefits and potencial hJfInS
lit" m"mmogral'h~' improves wiLl! age fur
W('men between the ages of 40 and 70 (6)'
The updated l;SPSTf: lc'cOJ~uTI(':lld31ion endorses this
to starr $crcening. Ho\\'en~r,
:lpproJ.ch [() deciding when
(he cum:nr LJSPSTF is now furehcr illformed by J new
s),stematic re\'iew (7), whicll in(:orporates a new random
ized, controlled trial that estimates the "number needed to
icvite for screening to extend one woman's life" as 1904
for women aged 40 to 49 years and 1339 for women
50 to 59 years. Although the relative risk reduction is
nearly identical (15% and 14%) for these 2 age groups, the
risk for breast cancer increases steeply with age starring at
age 40 years. Thus, the absolute risk reduction from
screening (as shown by the number needed to inyite to
screen) is greater for womell 50 to 59 ycars rhan for
those aged 40 to 49 years.
The currenr USPSTF statement is also informed by
the Cancer Intervention and Surveillance !'.10dcling >Jet
work (ClSNET) modeling studies (8) that accompany this
recommendation. The Task Force considered both "mor
tality" and "life-years gained" OUlcomes. III this case, given
that the age groups (40 to 49 years and 50 to 59 years) are
adjacent, (he Task Forct e1encd to emphasize the mortality
ourcomes from the modeling studies. Of the 8 screening
strategies found most efficient, 6 Start at age 50 years rather
than age 40 years. The frontier CUf\'es for thc mortality
outcome show only small gains but larger numbers of
mammograms required when screening is started at age 40
years \'ersus age 50 years.
In conclusion, the liSPSTF reasoned that rhe addi
rional benefit gained by narting screening at age 40 years
rather than at age 50 years is small, and that moderate
harms from screening remain at any age. This leads to the
C recommelldation. The USPSTF notes that a "C" grade
is a recommendation against routine screening of women
aged 40 to 49 years. The Task Force encourages individu
alized, informed decision maleing about when to start
mammography screening.
NEEDS Ar<D GAPS
A series of randomized clinical trials that would com
pare the results of SlOpping brea$t cancer screening at dif
ferem ages (by hrsr comparing stopping scre(;'ning at age 75
rears with continued screening, and then further compar
ing stopping screening at earlier ages, depending on the
n:,uhs of the first study) would be ethical and informative.
Extended follow-up of this type of study might also
provide useful information about overdiagnosis in this age
group. In general, more swdies of ovcrdiagnosis, including
comparisons of liferime breast cancer incidence among
similar screened and unscreened 'women, \vould be helpful.
Studies on overdiagnosis might also include long-rerm
[ollow-up of women with probabJe missed cases of DClS
on the ba.:;is of microcalcihcations th:H were missed in an
earlier mammogram. Such studies could provide the per
centage of these women who develop invasive breast cancer
o\'er the next i 0 or more rears.
Randomized clinical trials of film versus digital mam
mography among women with dense breast rissue, with
sufhcic;-)t [o;low-up to detect st;ige shifts (reductions ot
,j , ' j 1
 eu N 1(.".L GUID ELI!''; ES Screening for Bre;.s;: Cancer
late~5tage cancer) or decreases in clinical int:::rval cases,
would :ilio be ethical and helpful.
Better ll.'1derstand.ing of cemin facets of ruInor biol~
ogy is needed. particula..rly how age, race. breast density.
and other factors may predispose cer-.". lin wom::n towa..rd
tlL"I10rS with faster grow-.h rates and greater lethality. This
would improve r.~e ability to deterll'Jne at diagnosis which
pacientS CQ.ll be treated minimally.
DrSCU;;SION
Burden of Disease
Breast cancer is the most frequently diagnosed can
cer in women in the United States, not including skin
cancer, and is .second only to lung cancer as a cause of
cancer deaths. ln 2008, an estimated 182 460 cases of
invasiv.e ca.'1cer and 67 770 cases of in siru breast cancer
were diagnosed and 40 480 breast cancer deaths oc
curred (9). The National Cancer Institute, on the basis
of Surveillance Epidemiology and End Result data, es~
tim ares the lifetime risk for a wom:an to develop breast
cancer at 12% (10). The risk for breast cancer increases
with age. The 1O~year risk for breast cancer is 1 in 69
for a WOman at age 40 years. 1 i11 42 at age 50 years, and
1 in 29 at age 60 years (ll). The incidence rate of breast
cancer has increased since the 1970s; however, recent
data show mat mis rate see.lns to be decreasing. bom
oyerall and on an age-adjusted basis. The incidence rate
in 2003 was 124.2 per 100 000 women, a 6,7% decrease
from the previ.ous year (12). Discontinuation of hor
mone replacement therapy may be largely responsible
for this observed decrease (12, 13), although slowed
gro"l1:h or even a decline in screening mammography
also may have contributed (14). Breast c:aneer mortality
has been decreasing since 1990 by 2.3% per year overall
and by 3.3% for women aged 40 to 50 years. This
decrease is largely attributed to the combination of
mammogr2.phy screening with improved treatment (15).
Scope of Review
The systematic evidence review undertaken in support
of this recommendation (7) addressed the: efficacy of 5
breast cancer screening methods for reducing breast ca.'l.cer
mortality-film mammography, CBE, BSE, digital marI:
mography, and MPJ- by usir.g published reports of r:an
domized, controlled screening r.:ials and specifically up~
dated ir.formation from mammography trials a..'11ong
women in the age groups of 40 to 49 years and 70 years or
older. Informacion on harms of breast cancer screening,
such as false-positive teSt results, pain, anxiety. and biopsy
rates. were sought from multiple sources, including system
atic reviews. meta-analyses, :and recently published litera
tUle. To assess the follow-up testing a.'1d other outcomes of
a mammography screening program, the re\'iewers in
cluded data trom t.~e Breast Ca.ncer Surveillance Consor
tium from 2000 to 2005.
In addition to the systematic review of scree:ling tests,
the USPSTF requested a report from the CISNET Breast
Cancer Modding Group to provide data from comparaciye
decision modds on opci.r::lal mning and stopping ages a.'1d
intervals for screming mammography (8).
Accuracy of Screening Tests
Mamrnograpby, CBE. and BSE are recognized ap
proaches for breast cancer screening. Since the 2002
USPSTF recommendation statement. digital (as opposed
to Elm-based) mammography has been increasingly used,
and l\1RJ is being used with greater frequency for screeni.:lg
women at increased risk for breast cancer. The ser.siri"ity
of mammography screening is 77% to 95%, vvhe:eas spec
ificity is 94% to 97% (16). Multiple factors, including age,
time sIDce last ex2lllination. breast tissue density, equip
ment. and the skill of t.~e interpreting radiologisr can affect
sensitivity and specificity (17). A single, large compa..rison
. srudy of film and digital mammography (18) de.nor.strated
similar diagnostic accuracy for the 2 methods, althougb.
digital mammographyv.'a5 bener at detecting lesions in
women who were younger thw 50 years or premenopausal
or had r:l.diographidly dense breasts. Studies of MRI in
high-risk women without cancer (19) showed that Y..RI
has a sensitivity of 71 % to 100% and a specificity of B1%
1:0 97%; MRI is therefore recominended by the .American
Cancer Society for women at high risk for breast cancer.
However, no srudies have been done on using MPJ to
screen women at average risk.
Clinical breast aarnination has a sensitivity of 40% to
69% a.'1d a specificity in ~e range of 88% to 99%. For
BSE, sensitivity ranges from 12% to 41 %. lower tha.'1 that
of CBE and mammography, wd is age-dependent (16).
Effectiveness of Early Detection
The nev,'ly updated meta-analysis by Nelson and col~
leagues (7) connrms an earlier find.ing (16) t.~at screening
mammography reduces monality. Improvements in the
relative risk (RR) for deam due co breast cancer for women
aged 39 to 49 years and 50 to 59 years are simil:u- at 0.85
(95% CT, 0.75 to 0.96) and 0.86 (CI, 0.75 to 0.99), re
spectively. AIl even greater improvement was found for
women aged 60 to 69 years (RR. 0.68 [CIt 0.54 to 0.87]).
Results were uncertain for older women, v.ith a new report
from a previously included trial with longer follow-up data
showing an RR of 1.12 (CI, 0.73 to 1.72) for breast cancer
de.ath associated with screening women aged 70 to 74 years
(based on a .small number of participants). At t.~e ti.'11e of
the previous meta-analysis. data trom 2 trials showed an
RR of 0.78 (CI, 0.62 to 0.99) for breast cancer death in
screened women aged 65 to 74 years (16). Mor..ality reduc
tion a.'l.d life.-years gained (8) were both consicered L'TIpOr
tant outcomes of screer-ing in forming this recomme...'1da
don; in me end. mortality reduction as. observed in trials
was me metric chosen w express tI:lI~ benefirs of scm:.!".ing
.in e41ch z.ge group. Digital mammography has been sho'i'.'TI
co perform similarly to film mammography, although it
 Scre~ning fe.r Brea.'t Can cer I J"1(;\.1

has never been srudied in rcLltion 10 health Olllcomes. Clinical Breast Examination
~\'lagnetic resonance imaging has nor been evaluated for its A theoretical harm of eBc is lhat its lower specitci,y
potencial benefit in screening averilg,c-ri:;k women. Clini::al than that of mammography may result ill more women
breast examll1JtiOIl is inexpensi\'c and easy to perform; undergoing biopsy. Few data are available to evaluate
however, few studies have compared the cffccrivene$s of harms associated wilh eRE.
eRE with that of no screening and none has examincd
CBE and mammography versus mammography alone,
Breast SelfExamination
Two large trials of reaching BSE olmidc the United States
One study indicated that anxiety was not a concern
(7) del710flstraled no monaliry benefit in Ihe illtervendoll
with BSE. The 2 available trials (20, 21) indicated that
groups.
more additional imaging procedures and biopsies were
Potential Harms of Screening done for woml'n who performed BSE than for cOl1trol
Mammography partiClp:l11ts.
False-positive results are common with mammography
Estimate of Magnitude of Net Benefit
;lnd Ciin calise anxiety and lead to additional imaging stud
1n 2002, the USPSTF concluded that there was fajr
ies and il:vasive procedures (such a:; biopsy or line-lJeedle
evidence that mammography screening t"'ery 12 to 33
aspiration). Fahe-positive results ilnd accompanying addi
momhs could significantly reduce bre,lst carlcer mortality.
tional imaging studies are more common in younger
Tbe evidence was strongest for women aged 50 to 69 rears,
women. Biopsies may occur as a consequence of false
with weaker evidence supporting mammography screening
positive mammography results; biopsy rates arc more com
for women aged 40 (0 49 years. Since that recommenda
mon among older women. Anxiety, distress, and other
tion, I new trial and updated data from an older study
psychosocial effects can exist WiUl :abnormal mammogra
have been published thar specifically address screening in
phy results but fOf[unareiy are usually rransiem, and some
women in the younger age group. These findings were
research suggests that tbese effects are !lot a barrier to
combined in an updated meta-analysis, which resuJled in
screening, False-negarive results occur at a relatively low
anRR for breast cancer death of 0,85 (CI, 0.75 lO 0.96; 8
ratc for all ages, but are slightly higher in women older
trials) and a number needed to invite for screening of [904
than 70 years. Other potential harms, such as pain caused
by the procedure, exist bur are thought [0 have little dfect
(Cl, 929 to 6378) to prevent 1 breast cancer death in
women aged 39 to 49 years. A meta-analysis of 6 trials
on mammography use,
among women aged 50 to 59 years and 2 trials among
Overdiagl1osis can occur when screening detects early
women aged 60 lO 69 years provided pooled RRs for breast
stage invasive breast cancer or DClS in a woman, typically
cancer death in the screened group of 0,86 (CL 0.75 to
older, who is likely to die from another cause befnre the
0.99; number needed to in\'i1e, 1339 [CI, 312 to 7455])
blea.,t cancer would be clinically detected. Overdiagnosis
and 0.68 (Cr, 0.54 to 0,87; number needed to invite, 377
can J.lso occur in younger women if a detened DClS or
other early-stage lesion never progresses to im'asive cancer.
lei, 230 to 1050]), respectively. Only 1 smdy provided
data Oil women older than 70 years, yielding anRR of 1. J1
\1cthods for estjmating overdiagnosis at a population level
(C1. 0.73 to 1.72), although an RR of 0.78 (CI, 0.62 to
are nor well e:.;tablished, and thus the proportion of all
0,99) was found for women aged 65 to 74 vears b\' com
detecn:d DClS lesions that constitUte o\'erdiagnosis is un
bining the results of 2 studies ~used in the 2002 rc\;iew.
certain (7)_ Similarly, unnecessary earlier treatment can oc
A decision analysis performed for the USPSTF pro
cur at any age when screening detects a slower-growing
jecced that biennial screening produced 70% to 99% of the
cancer chat would have eventually become clinically appar
benefit of annllal screening, with a significant reduction in
ent but would never have caused d::ath.
the number of mammograms required and therefore a de
Ra,diatiofl exposure may illcrease the risk for breast
creased risk for harms. Screening between the ages of SO
cancer, but usually only at much higher doses than those
and 69 years produced a projected 17% (range, 15% to
used in mammography, although regular mammography
23%) reduction in morralit}' (compared with no scrcen
could contribute to cumulari\'e radiation doses from addi
ing). whereas eXlending the age range produced only minor
tional imaging [or other reasons (7).
improvements (additional 3% reduction from starting ar
age 40 years and iOt'h from extending to age 79 years) (8)_
Digital Mammography and Magnetic Resonance Imaging The USPSTF noted with moderate certainlY that the
Digiral mammography can be expected to have harms net benefit~ of screening mammography in wom;n aged 50
"imi!ar ro those of film mammography, No "tudies h3.\'c to 74 years were at least moderate, and that the greatest
evaluared MRI screening of average-risk women; in tht:Ory, benefi~ were seen in women abed 60 to 69 ye~s. For
because MRI could be considembly Ie~s specific than mam women aged !to to 49 years, the USPSTF had moderate
mography screening, it could potentially be associated with certainf}' that the net benefits were smaiL Because of d:e
higher biopsy rates and greater degrees of overdiagnosis if uncertainties related to harms of screening. particularly
t:sed in lew-risk port:l:l[ions. ovcrciiagnosis. and the near toral lack of trial data for older
wv;w.annals,orE
J
women, the USPSTF had low cerratl1ty about
,.,.. L t
net ben me
ems ot screen:ng mammograpr.y ,or women 75 years or
older.
How Does Evidence Fit With Biological Understanding?
Current knowledge about the development of breast
cancer is limited. The effectiveness or screening mam
mography seen in trials presumably results from the
early detection of smaller, earlier-stage tumors, which
are more responsive to available treatments. ,Although
the roost common breast cancer occurs in the epithelial
cdls that line the duct system of rhe gland (ductal car
cinoma), the sequence of development of invasive can
cer is not entirely known. For example, DCIS does not
always represent a precursor to invasive ducral cancer.
Studies of women with unueated DCIS showed pro
gression to invasive disease in half or fewer of the cases.
Because DCIS is orren found only by mammography, its
incidence has increased s:eadily since the advent of
widespread screening mammography. In 1983. 4900
cases of DCIS were diagnosed; by 2008, that number
was expected to be 67 770 (22). Because the likelihood
that DCIS will progress to invasive cancer is unknown,
surgical removal-with or without adjuvant treatmem
may represent overdiagnosls or oyertreatment. Lobular
carci.noma in situ, in coorrast, is not considered a true
precursor lesion but connotes a higher risk for subse
quent invasive lobular or ducal cancer in either breast.
Lobular carcinoma in situ is often multifocal, appearing
in several distinct locations. Knowledge of ...v hat deter
mines the rapidity with which invasive cancer can
spread (rcr::lor characteristics, host factors, hormonal
trIggers) is limited (23). Because of these dements of
biological uncert;linty, it is dear that lesion sensitivity
alene is not a su.ffi:::ient metric for ass::ssing effectiveness
of new screeningn'iethods (24).
UPDATE OF PREVIOUS USPSTF RECOflllMENDATION
This recommendll.uon updates the 2002 recommenda
tion by providing specific recomme-'1dations for mamr.:lOg
raphy screening by age. The previol!s recommendation
statement recommended screening mammography every 1
to 2 years for all women older tha.'1 40 years. The USPSTF
now recommends against !Curine screening of women aged
40 to 49 rars (C recommendarion), recommends biennial
screening r.t:unmography for all women aged 50 to 74
years (B recommendation), ~.,d provi.des an I sratement
regarding screening of women oider than 75 years. The
USPSTF now recommends against teaching ESE (D rec
ommendation), replacing ,he previous statemer..t of insuf
ficient evidence:. Tne evidence for continues to be
assessed as insufficient. Digital maJ'nmography a.'1d MRI as
. ocre::l1.ing tools were not addressed in the 2002 recommen
dation m.ternem; the USPSTF concludes t,l,.at the evidence
is insuFficient to assess the burns or bc:ne:ir.s of (.i.esc: rnee.h
ods for screening.
722117 "c"~rnbc, 20091 f~m::J, nfl"'<["~i \bJi.:in< 1Volume l51 Numb", 10
RECOIIIJlJ.EHDATIONS OF OTHERS
Numerous organizations have provided b:east canc:::r
screening recommenda:ions. These recomme.nciacions are
summariz.ed below..All recommendations are for women
not at increased risk for breast cancer. .
In 2003, the i\..."Deric211 C:l1lcer Society recom
mended annual mammography beginnL."lg at doge 40
years, annual CBE after ui.e age of 40 years (25). It does
not recommend MPJ for women at average risk for
b;-east cancer and st;;.tes that there is insufficient evi
dence to recommend BSE.
The .American Merucalll.Ssociation, in 2002 (26), and
the National Comprehensive Cancer Network, in 2009
(27), have made recommendations similar to those of the
American Cancer Society, except for the inclusion of a
positive recommendation for BSE.
The American Academy of Family Physicians has en
dorsed the USPSTF recor:::lJllendation on breast cancer
screening in the past (18). The American College of Phy
sicians recommended in 2007 that screerung mammogra
phy decisions ill women aged 40 to 49 yea:s should be
b;:sed on individualiz.ed assessment of risk for breast can
ce.r; that clinicians should inform women aged 40 to 49
years about ,he potential benefits and harms of screening
mammography; and that clinicians should base screening
ma.'Tlmography decisions on bendir.s and harr..5 of screen
ing, as well as on a woman's preferences and breast cancer
risk profile (29).
In 2001, the Canadia.'1 TO?Sk Force on Preventive
Health Care recommended mm:unography every 1 to 2
years beginning at the :age of 40 years and recommended
CBE as part of a periodic evaluation (eyery 1 to 3 years) for
women aged SO to 69 years (30). It does not recommend
BSE.
In 2003, the .American College of Obs:e::rics and Gy
necology recommended ma:r.mography every I to 2 years
for women aged 40 to 49 years and a.'1nualJy after th.e age
of 50 years (31). It recommended CBE for all women. a..,d
Dored that BSE can be recoI!4-ncoded.
In 1009, the World Health Or~anization recom
mended mammography every 1 ro 2 yea7:s for women aged
50 to 69 years, but docs not recom:nend CBE or BSE (32).
From th~ U.S. Prcv~nciv~ Services T;sk Force, Agency for He..I6=~
~.earcb and Qu:ility. Roci..."illc, M:1..'yiL'ld.
Disclaimer: Recor:um:ndltcions m"d~ by th~ USPSTF are indc:pc..'ldent of
t.he U.S. gove:nment. They should nor be c:onscnw::! IlS ~n o:nci:J pmi ..
~ion of the Agen:y for Heal ::hare Rcse;rch 2nd Qu~ity 0 r the U.S.
Dep:lI"CTlenc of H~::h and Hwn:rn Services. .
Financi;:l Support: The USPSTF is an i.ndepend~l, yoiu..::.'Il'Y bod)'.
The U.S. Congrcss mwda:6 that the Agency for neol::h=e Research
;,nd Qu:ali!}' suppOrt the Ope::lDons of the USPSTF.
Potential Conflim of interest; None disclosed.
WI'IW.lnnaI1.Or~