In the November 17 issue of Annals of Internal Medicine, the U.S. Preventive Services Task Force (USPSTF) updates its recommendations on screening for breast cancer in the general population (see www.annals.org), including the following:

• The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. (grade C recommendation)
• The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. (grade B recommendation)
• The USPSTF recommends against teaching breast self-examination (BSE). (grade D recommendation)

The American College of Obstetricians and Gynecologists, however, currently continues to recommend the following services:

• Screening mammography every 1-2 years for women aged 40-49 years
• Screening mammography every year for women age 50 or older
• BSE; BSE has the potential to detect palpable breast cancer and can be recommended.

The College is continuing to evaluate in detail the new USPSTF recommendations and the new evidence considered by the USPSTF. Any changes to College guidance will be published in its journal Obstetrics & Gynecology.

Why did the USPSTF recommendations change?

Mammography in Women Aged 40-49 Years

In 2002, the USPSTF recommended screening mammography, with or without clinical breast examination, every 1-2 years for women aged 40 and older (grade B recommendation). The new USPSTF recommendations are based on a systematic evidence review by Heidi D. Nelson, MD, MPH, and colleagues and a modeling study by Jeanne S. Mandelblatt, MD, MPH, and colleagues published in the same issue of Annals of Internal Medicine.

The 2009 USPSTF judged that, although women in their 40s and women in their 50s benefit equally from routine screening mammography, women in their 40s experience greater harms from screening than women in their 50s. The harms assessed by the USPSTF were radiation exposure, false-positive and false-negative results, overdiagnosis, pain during procedures, and anxiety, distress, and other psychologic responses. Therefore, the USPSTF recommended routine screening for women aged 50-74 but recommended against routine screening for women in their 40s.

Breast Self-Examination

In 2002, the USPSTF judged that evidence was inadequate to make a recommendation on teaching or performing BSE. The new USPSTF recommendations are based on a systematic evidence review by Heidi D. Nelson, MD, MPH, and colleagues published in the same issue of Annals of Internal Medicine. This systematic evidence review identified two studies published since the 2002 recommendations. These studies found that teaching BSE did not reduce breast cancer mortality but resulted in additional imaging procedures and biopsies. Therefore, the USPSTF recommended against teaching BSE on the grounds that it has no benefit for women but places them at risk of harm.

What Should Fellows Do?

At this time, The American College of Obstetricians and Gynecologists recommends that Fellows continue to follow current College guidelines for breast cancer screening. Evaluation of the new USPSTF recommendations is under way. Should the College update its guidelines in the future, Fellows would be alerted and such revised guidelines would be published in Obstetrics & Gynecology.

The College continues to recommend that Fellows advise mammography screening for their patients aged 40 and older and that they counsel their patients that BSE has the potential to detect palpable breast cancer and can be performed. Fellows should be aware that the new USPSTF recommendation against routine screening mammography for women aged 40-49 (a grade C recommendation) has implications for insurance coverage, as some insurers will cover only preventive services rated as an "A" or a "B" by the USPSTF. Fellows should counsel their patients that insurance coverage for "routine screening" mammography may become variable and that patients should address this question with their insurers. These recommendations do not apply to high-risk women or patients with clinical findings, and they should be managed accordingly.

* For additional information, see "Interpreting the USPSTF Breast Cancer Screening Recommendations for the General Population," available at: http://www.acog.org/from_home/Misc/uspstfinterpretation.cfm