USPSTF: No routine mammography for women younger than 50 years

Clinical question When and how should women be screened for breast cancer?

Bottom line The US Preventive Services Task Force (USPSTF) recommends against routine screening mammography for women aged 40 to 49 years (Grade C recommendation). They continue to recommend screening every other year between the ages of 50 and 74 years (Grade B), but stop short of recommending continuing screening after that. In another turnaround, they also recommend against teaching breast self-examination (Grade D) and give an “insufficient evidence” rating (Grade I) to clinical breast examining, digital mammography, and MRI. These guidelines are more in step with recommendations in other countries. In the United States, the American College of Physicians is the only other group that does not recommend screening mammography in women younger than 50 years. (Level of evidence = 1a)

Synopsis Updating their guidelines from 2002, the USPSTF commissioned a meta-analysis and a decision analysis to weigh the benefits against the risks of screening for breast cancer. The meta-analysis was conducted using the usual methods and included additional results from a study conducted in the United Kingdom. The decision analysis evaluated different models to determine the best trade-off between benefit and risk (false-positive results) of mammography screening. Based on these analyses, the group changed their recommendation for women aged 40 to 49 years to recommend against screening in this age group (Grade C recommendation: moderate to strong evidence of a small benefit), with the caveat that screening will be suitable for some women. They recommend every other year mammography for women aged 50 years to 74 years (Grade B recommendation: moderate evidence of moderate benefit). They conclude the evidence is insufficient to support or oppose screening mammography for women 75 years or older (Grade I recommendation: insufficient evidence). They also deviate from accepted practice with their guidelines for manual examination, recommending against teaching breast self-examination (Grade D recommendation: moderate to high evidence of no benefit or evidence of harm) and giving no recommendation regarding clinical breast examination (Grade I). Similarly, they give no recommendation regarding the use of digital mammography or MRI.

US Preventive Services Task Force. Screening for breast cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151(10):716-726. Nelson HD, Tyne K, Naik A, et al; US Preventive Services Task Force. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 2009;151(10):727-737. Mandelblatt JS, Cronin KA, Bailey S, et al; Breast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network. Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms. Ann Intern Med. 2009;151(10):738-747.