Among all women in the United States, breast cancer is the second most common cancer and the second leading cause of cancer-related deaths. In 2023, an estimated 43,170 women lost their lives to breast cancer. The incidence of breast cancer has been gradually increasing among women aged 40 to 49 years from 2000 to 2015, but the rate of increase became more pronounced from 2015 to 2019, with an average annual increase of 2.0%.
In observance of Breast Cancer Awareness Month 2024, this article will provide a comprehensive comparison of current clinical practice guidelines from the American College of Obstetricians and Gynecologists (ACOG), the American Cancer Society (ACS), and the US Preventive Services Task Force (USPSTF). By examining and comparing these guidelines, the aim is to provide healthcare providers with valuable insights and best practices for the assessment of breast cancer. This evidence-based approach is crucial in addressing the rising prevalence of breast cancer and improving health outcomes for the many women affected by this disease. Breast cancer risk assessment plays a vital role in identifying women who may benefit from more intensive surveillance and monitoring.
Titles of Comparison:
- Screening for Breast Cancer
- Published by US Preventive Services Task Force (USPSTF) in April 2024.
- Objective: The USPSTF commissioned a systematic review to evaluate the comparative effectiveness of different mammography-based breast cancer screening strategies by age to start and stop screening, screening interval, modality, use of supplemental imaging, or personalization of screening for breast cancer on the incidence of and progression to advanced breast cancer, breast cancer morbidity, and breast cancer–specific or all-cause mortality, and collaborative modeling studies to complement the evidence from the review.
- Target Population: Cisgender women and all other persons assigned female at birth aged 40 years or older at average risk of breast cancer.
- Methodology: USPSTF commissioned a systematic review4,50 on the comparative effectiveness of different mammography-based breast cancer screening strategies by age to start and stop screening, screening interval, modality, use of supplemental imaging, or personalization of screening for breast cancer on the incidence of and progression to advanced breast cancer, breast cancer morbidity, and breast cancer–specific or all-cause mortality.
- In addition to the systematic evidence review, the USPSTF commissioned collaborative modeling studies from 6 CISNET (Cancer Intervention and Surveillance Modeling Network) modeling teams to provide information about the benefits and harms of breast cancer screening strategies that vary by the ages to begin and end screening, screening modality, and screening interval.
- Graded Strength of Recommendations: Yes
- Graded Level of Evidence: Yes
- Systematic Review Conducted: Yes
- Literature Review Conducted: Yes
- Breast Cancer Screening for Women at Average Risk
- Published by the American Cancer Society (ACS) in October 2015.
- Objective: To update the ACS 2003 breast cancer screening guideline for women at average risk for breast cancer.
- Target Population: Women at average risk of breast cancer
- Methodology: 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.
- Graded Strength of Recommendations: Yes
- Graded Level of Evidence: Yes
- Systematic Review Conducted: Yes
- Literature Review Conducted: Yes
- Breast Cancer Risk Assessment and Screening in Average-Risk Women
- Published by the American College of Obstetrics and Gynecologists (ACOG) in July 2017.
- Objective: The purpose of this Practice Bulletin is to discuss breast cancer risk assessment, review breast cancer screening guidelines in average-risk women, and outline some of the controversies surrounding breast cancer screening.
- Target Population: Women at average risk of breast cancer
- Methodology: This Practice Bulletin was developed by the Committee on Practice Bulletins—Gynecology in collaboration with Mark Pearlman, MD; Myrlene Jeudy, MD; and David Chelmow, MD.
- Graded Strength of Recommendations: Yes
- Graded Level of Evidence: No
- Systematic Review Conducted: Yes
- Literature Review Conducted: Yes
Comparison Content:
| Screening for Breast Cancer | Breast Cancer Screening for Women at Average Risk | Breast Cancer Risk Assessment and Screening in Average-Risk Women | |
|---|---|---|---|
| Society/ Organization | US Preventive Services Task Force (USPSTF) | American Cancer Society (ACS) | American College of Obstetrics and Gynecologists (ACOG) |
| Starting Age | 40 years | 45 years | 40 years |
Frequency | Every 2 years | Every year for ages 45-54, biennial screening for ages 55-74 | Every 1 or 2 years |
| Ending Age | The current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women 75 years or older. | Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer. | Continue until age 75, beyond age 75 should be based on shared decision-making. |
| ClinicalBreast Exams | Not specifically addressed. | The ACS does not recommend clinical breast examination (CBE) for breast cancer screening among average-risk women at any age. | May be offered every 1-3 years for women aged 25-39. Recommended annually for women 40 and up. |
| Risk Assessment | Emphasis on individual risk factors for tailoring screening. | Encouragement of risk assessment to guide individualized screening. | Strong emphasis on assessing risk factors to determine screening frequency. |
| Potential Harms | Pain during mammography, false positives, overdiagnosis, unnecessary biopsies, anxiety, radiation exposure | False positives, overdiagnosis, unnecessary biopsies, anxiety, radiation exposure | Cost, anxiety, inconvenience, false-positive results, and other test-specific harms such as overdiagnosis and overtreatment |
| Decision-Making | Not explicitly mentioned | Encourages informed decision-making | Emphasizes shared decision-making between patient and clinician |
| Special Notes | More research needed for women 75+ | Women 40-44 can choose to start early | Screening mammography every 1 or 2 years based on informed decision-making |
Key Differences:
- Starting Age: USPSTF and ACOG recommend starting at age 40, while ACS suggests starting at age 45
- Frequency: ACS recommends annual screening for women aged 45-54 and biennial screening for women aged 55-74, whereas USPSTF and ACOG recommend biennial screening for most age groups
- Decision-Making: ACS and ACOG emphasize informed and shared decision-making between patients and their healthcare providers
Summary:
These recommendations signify the advancing comprehension of cancer risk and the significance of personalized care in screening protocols. The suggested age to commence cancer screening typically commences at age 40, with discrepancies in frequency and recommendations for clinical examinations. Both USPSTF and ACOG advocate for annual screening starting at age 40. Conversely, ACS proposes that annual screening should commence at age 45. It is important to note that all guidelines underscore the importance of taking into account individual risk factors when determining the most suitable screening approaches.
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