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Primary Care
CMECNE

Mammography Guidelines for Average-Risk Women

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Restate the definitions of overdiagnosis vs overtreatment
2. Counsel patients about breast cancer screening guidelines

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 20189, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

SUMMARY:

Professional organizations continue to release evidence based guidance on mammography, with ACP the latest to provide updated recommendations. While required frequency and starting age may differ, they all emphasize shared decision making with patients, which entails counseling about uncertainty, risk/benefit and related patient values.

BENEFITS OF MAMMOGRAPHY

  • Appears to decreases breast cancer mortality by 15 to 20%
    • Studies demonstrate varying magnitude
    • ACS (RCT data): Relative risk 0.80-0.82
    • Recent data from the Canadian National Breast Screening Study did not show decrease when comparing mammography to controls perhaps due to more recent improvements in treatments but does not take in to account advances in imaging
  • Reduces advanced cancer (although no evidence regarding advanced cancer treatment)
    • USPSTF evidence review in women > 50 years of age: Relative risk 0.62 (95% CI, 0.46 – 0.83)
  • May increase life expectancy (ACS systematic review) but could not quantitate

HARMS OF MAMMOGRAPHY

False Positives (additional images and benign biopsies)

  • USPSTF review 10 yr cumulative false positive rate
    • Annual: 61% false positive / 7% require biopsy
    • Every 2 years: 42% false positive / 5% require biopsy
  • ACS review of the same data
    • Increased risk of false positive with dense breasts among women 40-49
    • Callbacks minimized if prior films available

Anxiety and Distress

  • May persist even if follow-up is normal
  • Financial concerns as patient may be responsible for paying for additional tests

Discomfort

  • USPSTF review identified mammography as being a painful procedure
  • Follow-up procedures may also result in pain

Overdiagnosis and Overtreatment

  • Overdiagnosis is defined as detecting a cancer that would have remained indolent and not become apparent without screening
  • Overtreatment is defined as treatment for an overdiagnosed cancer
  • Difficult to discern actual number of overdiagnosed cancers
    • USPSTF review suggests 10.7% – 22.7% based on RCT data
    • 1/8 cancers will be overdiagnosed and 2 to 3 women will be treated unnecessarily
  • Inclusion of Ductal Carcinoma in Situ may impact data
  • Other organizations such as ACS make the point that certain assumptions may not be verifiable in addition to bias in methodology and design

Radiation

  • USPSTF using modelling but not direct studies of radiation exposure estimates 2 per 100,000 deaths among women 50-59 yrs due to mammography screening
  • Other models in women 40-74 yrs suggest 125 cases of breast cancer and 25 cancer deaths due to radiation exposure, but 986 cancer deaths prevented

PROFESSIONAL GUIDELINES:

ACOG 2017

  • Start Age
    • Recommend at age 50
    • Offer from age 40 (shared decision making)
  • Screening Interval
    • Every 1 or 2 years (shared decision making)
  • Stop Age
    • Age 75
    • > 75 shared decision making including overall health and longevity

USPSTF 2016

  • Start Age
    • Recommend at age 50
  • Screening Interval
    • > age 50: every 2 years until age 74
  • Stop Age
    • ≥ age 75:  Insufficient evidence to recommend for/against

ACS 2015

  • Start Age
    • Recommend at age 45
  • Screening Interval
    • Age 45 – 50 age: annual
    • 55 yrs: Every 2 years or can choose annual
  • Stop Age
    • Continue if good health and life expectancy >10 years

ACR 2010

  • Start Age
    • Recommend at age 40
  • Screening Interval
    • Annual
  • Stop Age
    • Stop when life expectancy is less than 5 to 7 years because of age/comorbid conditions

ACP 2019

  • Start Age
      • Offer at age 50
    • Age 40 – 49: Discuss risks vs benefits and patient preference (“potential harms outweigh the benefits for most women” in this age bracket )
  • Screening Interval
    • Every 2 years
  • Stop Age
      • Screening not recommended for women ≥75
    • Life expectancy ≤10 years

AAFP 2016

  • Start Age
    • Recommend at age 50
  • Screening Interval
    • Every 2 years
  • Stop Age
    • ≥ age 75:  Insufficient evidence to recommend for/against

NCCN 2019

  • Start Age
    • Recommend at age 40
  • Screening Interval
    • Annual
  • Stop Age
    • Upper age limit not yet established
  • Consider comorbidities that may impact life expectancy (≤10 years)

Canadian Task Force on Preventative Healthcare 2018

  • Start Age
    • Recommend not to screen women age 40 to 49 (conditional recommendation; low-certainty evidence)
  • Screening Interval
    • Every 2 to 3 years
    • 50-69 years: “Conditional on the relative value that a woman places on possible benefits and harms from screening (conditional recommendation; very low-certainty evidence)
    • Age 50-59: 1333 women is the number needed to screen (NSS) to prevent one death from breast cancer (95% CI, 909 to 2857)
    • Age 60-69: NSS is 1087 (95% CI, 741 to 2325)
    • Age 70-74: NSS is 645 (95% CI, 441 to 1389)
  • Stop Age
    • No evidence found regarding harms vs benefits of screening ≥75 years

Note: The Canadian Task Force did not make any significant change from the previous guideline, however certainty of evidence – now ‘very low- to low-certainty’ was downgraded based on serious concerns of previous study bias

American Society of Breast Surgeons 2019

  • Start Age
    • Non-dense breasts (A and B density): 3D preferred modality | Age 40 | No need for supplemental imaging
    • Dense breasts (C and D density): 3D preferred modality | Age 40 | Consider supplemental imaging
  • Screening Interval
    • Annual
  • Stop Age
    • When life expectancy is <10 years

ADDITIONAL KEY POINTS: 

  • Clinical Breast Examination (CBE)
    • ACOG & NCCN: Offer every 1 to 3 years for women ages 25-39 and annually for ≥ age 40
    • USPSTF & AAFP: Insufficient evidence to recommend for or against
    • ACS, ACP & Canadian Task Force on Preventative Healthcare: Not recommended
  • Most professional organizations find insufficient evidence to recommend adjunctive screening using breast ultrasonography, MRI, Digital Breast Tomosynthesis, or other method in the setting of a normal mammogram and no other risk factors

Learn More – Primary Sources:

ACOG Practice Bulletin 179: Breast Cancer Risk Assessment and Screening in Average-Risk Women

Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement

Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial

Canadian Task Force: Recommendations on screening for breast cancer in women aged 40–74 years who are not at increased risk for breast cancer

Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer

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

Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians

AAFP: Summary of Recommendations for Clinical Preventative Services

NCCN Guidelines: Breast Cancer Screening and Diagnosis

ASBrS: Position Statement on Screening Mammography

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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