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American Society of Breast Surgeons Issues First Risk-Based Screening Guidelines

With an explicit focus on saving lives, the American Society of Breast Surgeons (ASBrS) recently released the first screening mammography guidelines based on a patient’s individual breast cancer risk profile, with clear, specific strategies for screening management.

“Our members are on the front lines with breast cancer patients every day guiding them through all stages of breast cancer diagnosis and treatment. These new recommendations were ASBrS member driven and developed based on their unique, firsthand perspective on the disease and patient journey. They represent a deep, passionate, and scientifically backed commitment to advocate for increased years of life over costs,” says Shawna Willey, MD, FACS, ASBrS chairman of the board, a professor of clinical surgery and director of MedStar Regional Breast Health Program, and chief of surgery at MedStar Georgetown University Hospital in Washington, D.C. “They also aim to minimize breast cancer disparities across race and ethnicity through earlier disease detection for all.” 

The new recommendations differ from current United States Preventive Services Task Force (USPSTF) and American Cancer Society guidelines, which apply only to women with average risk and also factor in screening costs per diagnosis and related issues along with mortality, but are supported by the ACR. 

Drawing on the strongest body of currently available research on the impact of breast cancer screening, the guidelines recommend that all women undergo formal risk assessment by age 25. For women with average risk, annual screening starting at age 40 is recommended. For women with increased likelihood of developing the disease, the guidelines call for a range of more comprehensive screening strategies based on specific risk factors. For example, for those with a predicted breast cancer lifetime risk of more than or equal to 20%, they call for mammography and access to supplemental MRI imaging starting at age 35. For women with breast cancer–related genetic abnormalities, they call for similar imaging starting at age 25. 

“Routine screening for women age 40 to 49 has been unequivocally demonstrated to reduce mortality by 15%. However, USPSTF guidelines delay annual screening until age 50 because they are based on an efficiency statistical model that also considers the impact of potential screening risks,” notes Walton A. Taylor, MD, FACS, the president of ASBrS and the Texas Health Physicians Group in Dallas. “In addition to elevated costs, these include a statistical probability of false negative and positive results leading to unnecessary anxiety and additional medical procedures, overdiagnosis of indolent cancers, and increased radiation exposure.”

“ASBrS guidelines are based on a life-years gained model,” notes Julie Margenthaler, MD, FACS, director of breast surgical services of the Joanne Knight Breast Center at Siteman Cancer Center and a professor of surgery at Washington University School of Medicine in St. Louis. “They are based solely on the demonstrated breast cancer survival benefits. The ASBrS prioritizes life. Members put this priority to work every day when treating patients. We believe women should have an opportunity to choose earlier screening if potentially beneficial. Additionally, our understanding of breast cancer risks and risk assessment has advanced. Managing screening based on those risks is an important part of today’s personalized medicine.

“While mammographic screening is not as easy or accurate in younger women, when we find and treat cancer, the benefits in years of life saved are highly significant,” Margenthaler adds. “Many current guidelines will leave a subset of these women to die.”

In addition to formal breast cancer risk assessment for every woman, the new ASBrS recommendations contain many unique components distinguishing them from other existing academic and professional organization guidelines. These include the detailed stratification of risk, the specificity of actionable recommendations for each group, and suggestions for patient discussion and shared decision-making. The new guidelines also take into account specific breast cancer subtypes more common among certain racial and ethnic groups. They suggest enhanced surveillance leading to earlier diagnosis and treatment in an effort to achieve health care equality.

While most health insurers will cover some recommended strategies, such as risk assessment and 3D mammograms, before age 50, the ASBrS specifically did not restrict guidelines to currently covered procedures. “We want to be change agents on behalf of our patients and hope that these guidelines will encourage insurers to rethink some of their coverage policies,” notes Taylor.

“The ACR supports the American Society of Breast Surgeons recommendations that women start getting annual mammograms at age 40,” says Dana Smetherman, MD, chair of the ACR Commission on Breast Imaging. “The American Cancer Society, US Preventive Services Task Force, ACR, and the Society of Breast Imaging agree that the most lives are saved by this approach. Catching more cancers early by starting yearly screening at age 40—rather than less frequent or later screening—increases the odds of successful treatment and can preserve quality of life for women. We are pleased that ASBrS has reaffirmed their support for this most sensible approach.”