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No consensus on new breast screening guidelines

January 12, 2016 | Patricia Harriman
UCI Health breast imaging expert Dr. Stephen A. Feig

Dr. Stephen Feig, chief of breast imaging, UCI Health

Not all doctors are planning to follow the final breast cancer screening guidelines issued yesterday by the U.S. Preventive Services Task Force. According to the final recommendation, published Jan. 11 in the Annals of Internal Medicine, women with an average risk of breast cancer should undergo biennial screening beginning at age 50, and continue to age 74. For women aged 75 and older, the federal panel found insufficient evidence on which to base a recommendation.

The new task force guidelines update those issued in 2002, which recommended annual or biennial mammography screening for all women aged 40 and older.

“These (new) recommendations will not affect my practice,” says Dr. Stephen Feig, chief of breast imaging for UCI Health. “My duty is to my patients, and I will do what I think is best. The anxiety of false positives and unnecessary biopsies can’t compare with the anxiety of going through breast cancer. There is no way to balance lives saved versus the rates of false positives.”

Benefits of annual mammogram

Feig’s concerns are shared by his colleague, Dr. Freddie Combs, director of breast imaging at UCI Health Pacific Breast Care Center, who says that the panel's recommendations do not adequately recognize the importance of screening in women in the 40-49 age group. He believes that annual screening should begin at 40 for women of average risk.

“These new guidelines may result in fewer women in this age group choosing to be screened under the false assumption that there is no benefit,” Combs said. 

“A recent study in the American Journal of Roentgenology estimated that if women aged 40-49 are not screened, and women aged 50-74 are only screened every two years, the result will be approximately 6,500 more additional deaths in US women each year from breast cancer.”

Risk factors overrated

“If only those women with high risk factors are screened annually, 80 percent of breast cancers will be missed,” Feig says. “Most breast cancer is diagnosed in patients with no known risk factors, such as family history, dense breasts or other genetic markers.”

Annual mammograms should begin at age 40 because 20 percent of all breast cancer is found in women between the ages of 40 to 49, he said. Biennial screenings increase the risk of an early stage cancer being missed, when it is most treatable.

“Any surgeon, oncologist or radiologist will say that they would prefer to treat smaller tumors,” Feig says. “Cancers are most treatable when they are found early, so in terms of reducing the number of breast cancer deaths, there is a greater benefit for women in beginning annual mammography screenings at age 40.” 

Insurance coverage concerns

Another concern in the breast care community with the new USPSTF guidelines, Combs says, is that private insurers may soon no longer guarantee coverage for mammography screening for women 40 and over.

“Thankfully, with the recent Consolidated Appropriations Act which includes the Protecting Access to Lifesaving Screens Act, mandatory mammography insurance coverage is guaranteed for at least two more years,” he says.

“Currently, the Affordable Care Act requires private insurers to cover exams with a grade of B or higher. Routine screenings in the new recommendations for women 40-49 received a grade of C. This leaves the door wide open for many women to be put at risk by lack of coverage.”

New federal prevention guidelines

The final recommendations are tailored to age levels, and apply to women who are not high risk.

Risk factors include those with preexisting breast cancer or previously diagnosed high-risk lesion, genetic mutations, family history or have undergone chest radiation at a young age.

  • 40-49 years: Informed, individualized decision-making based on a woman’s values, preferences and health history. 
  • 50-74 years: Mammography every two years. 
  • 75 years and older: Current science is inadequate to recommend for or against. More research is needed. 

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