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How to make sense of the new mammogram guidelines

The American Cancer Society has revised its mammogram guidelines, recommending that women with an average risk of cancer start screenings at age 45, not 40. Judy Woodruff examines the guidelines and the debate with Dr. Richard Wender of the American Cancer Society.

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  • JUDY WOODRUFF:

    And now to the details of the breast cancer news.

    The American Cancer Society’s revised mammogram guidelines recommend that women with an average risk of cancer start annual screenings at age 45. That’s five years later than the society’s prior guidelines that recommended starting at age 40. There have been years of debate and numerous studies questioning the value of these screenings and the age at which they should begin, often forcing women to weigh the risk of false diagnoses and overtreatment vs. early treatment that can save a woman’s life.

    Here to explain the new guidelines, and the shift in thinking they represent, is Dr. Richard Wender. He’s the chief cancer control officer with the American Cancer Society.

    Dr. Wender, thank you for being with us.

    Why is 45 now the magic number, not 40, not 50, which some organizations still recommend?

  • DR. RICHARD WENDER, American Cancer Society:

    Well, there actually is no magic number.

    What our guideline group found is that the risk of breast cancer increases as a woman ages. And that’s really what determines the balance of benefits and harm. So, we actually recommend that all women start the discussion about mammography at 40, and we absolutely endorse women having the choice to begin screening at age 40.

    But we state that, by age 45, the benefits substantially outweigh the harms for the entire population. And that’s the age where all women should be starting regular annual mammography, assuming they have not started before age 45.

  • JUDY WOODRUFF:

    So what is the new information that has come in, in the last six years, since the American Cancer Society said it was most comfortable telling women to start at age 40? What makes you now comfortable to say that it’s 45?

  • DR. RICHARD WENDER:

    Well, actually, our last full guideline for average risk was written way back in 2003.

    So, back then, there was no expectation that guideline groups would balance the benefits and the drawbacks of screening. That now is a standard. We also have some new data about the interval for screening before menopause and after menopause.

    And there are also some new observational trials that actually tell us just how valuable mammography is. The goal of this new guideline is to highlight the populations who are at — most likely to benefit, most likely to have the greatest benefit, but, at the same time, giving women a choice to begin screening earlier and to continue screening more regularly beyond menopause based on her personal values and her preferences.

    But it’s important to understand that the risk of developing breast cancer at age 40 is actually still quite small, and that’s why there’s a greater likelihood that a woman will experience a false positive and a lower likelihood that she will get actual benefit.

    But many women place great value on the opportunity to prevent a breast cancer death. And we expect many women will want to continue starting at 40. But our message is very clear, that if you haven’t already started, please start regular mammography at 45, because this guideline really proves that the most effective thing that a woman can do to reduce her chances of dying of breast cancer are to have regular mammograms.

  • JUDY WOODRUFF:

    At the same time, it is a striking shift in the eyes of those who read what the American Cancer Society was saying some years ago.

    We found an opinion column that Dr. Otis Brawley, who was the chief medical officer for the Cancer Society — he wrote this in 2009. He said, not only should women start having mammograms, most women, at age 40. He said not doing so could be fatal, he said, for many women. He said turning the clock back will add up to too many lives lost.

  • DR. RICHARD WENDER:

    Well, the — I think you said it well. This will be seen as a dramatic shift.

    I think it’s actually a nuanced shift. This new guideline is more personalized, it’s more tailored. It helps women really have a road map to follow throughout her life in making screening decisions, helps her understand that, when you hit 40, the likelihood of benefit is lower and it gradually keeps going up because your risk of breast cancer goes up and makes that clear statement at 45.

    We looked at this issue of 50, and found that, actually, the balance of benefits and harms of screening for women 45 to 49 is actually quite similar for women 50 to 54. And we felt it was important that we give a clear message that all women should start by age 45.

    So, our last guideline was in 2003. The whole approach to thinking about screening has changed. There is a higher expectation that women be informed, be empowered to take into account their own personal values. And I think this guideline does just that.

  • JUDY WOODRUFF:

    Dr. Wender, what do you say to women, though, who may still be confused, because, as you know, there are other respected groups out there recommending different times? How do women make sense of all this? What should they do?

  • DR. RICHARD WENDER:

    Well, our old guideline, annual screening starting at 40, sounded very simple, but it wasn’t eliminating the confusion, because it was forcing women and clinicians to just make a choice, am I going to follow this guideline or am I going to follow the other guideline?

    This guideline actually takes a person through her lifespan and helps her get the information she needs to make a decision at each point along that journey. So, I think, although it is more complicated, it actually will create greater clarity.

    But it does mean three things. A woman is going to have to work hard to gather greater information to be more informed. Two, it creates an obligation for clinicians to really help women get this information and help them conduct a shared decision with their patients. And, three, it creates an obligation for organizations like the American Cancer Society to make sure that we have the information available for clinicians, for patients, and that we produce decision aids that can help really people make this decision.

    So, it is — it’s more nuanced, personalized, a bit more complicated, but we actually think it’s going to create greater clarity, not greater confusion.

  • JUDY WOODRUFF:

    And Dr. Richard Wender with the American Cancer Society, thank you.

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