The American College of Physicians has updated its breast cancer screening guidance, suggesting a risk-based approach that favors biennial mammograms for many women aged 50 to 74 while encouraging individualized discussions for those younger or older, touching off debate among experts about frequency, supplemental imaging and access to care.
The ACP now recommends that average-risk, asymptomatic women between 50 and 74 have mammograms every two years. That shift from annual checks for many reflects concerns about harms that can come from too-frequent screening, such as over-diagnosis and unnecessary treatment.
For women aged 40 to 49 the guidance urges a conversation with a clinician to weigh benefits and harms rather than issuing a blanket directive. The idea is to use risk assessment to determine who might need earlier or more frequent screening and who might safely space checks out.
The group cautioned that unnecessary screening can produce false positive results, psychological distress, over-diagnosis, over-treatment, additional testing and radiation exposure. It also noted that women 75 and older who are asymptomatic and at average risk, or who have limited life expectancy, can discuss halting screening with their doctors. “This is because the benefits of screening beyond age 74 are reduced or uncertain, while potential harms, such as over-diagnosis, become more likely with increasing age,” it said.
The committee encouraged clinicians to consider digital breast tomosynthesis, or 3D mammography, for patients with dense breasts while advising against routine use of supplemental MRI or ultrasound in average-risk populations. “Decisions should consider potential benefits and harms, radiation exposure, availability, patient values and preferences, and cost,” the group wrote. “However, ACP advises against using supplemental MRI or ultrasound for screening in this population.”
ACP’s Clinical Guidelines Committee defined “average-risk” as women without a personal breast cancer history, high-risk lesions, BRCA1 or BRCA2 mutations, another familial breast cancer risk syndrome or a history of high-dose chest radiation at a young age. Those who fall outside that definition are managed differently and often require earlier or more intensive screening.
Dr. Jason M. Goldman, president of ACP, stressed the role of evidence in shaping screening choices, saying screening for breast cancer is “essential and should be guided by the best available evidence.” “ACP developed this guidance to provide physicians and females with the information they need to make breast cancer screening decisions, including when to start and discontinue, how often to screen and which methods to use for screening,” he said.
Not everyone agreed. Lauren Carcas, a medical oncologist at the Miami Cancer Institute, cautioned that the new guidance could “add to the confusion of screening recommendations.” She argued that a risk-based approach assumes universal access to nuanced risk assessments and meaningful conversations with primary care or gynecologic clinicians. “Doing so implies that all women have equal access to individualized discussions and nuanced risk-assessment through either their primary care or gynecologic physicians.”
Carcas warned that shifting many women to biennial screening could widen disparities and raise the chance of missing cancers in populations already facing barriers to care. She also contested the ACP stance against supplemental MRI and ultrasound for women with dense breasts, noting that radiologic societies strongly favor adding those modalities for more complete imaging. “The radiologic societies very strongly recommend the addition and consideration of breast ultrasound and/or MRI for more complete and accurate imaging,” she said.
Major societies differ on the interval question. Some groups continue to recommend annual mammography starting at 40, while ACP emphasizes biennial screening for average-risk women starting at 50. Carcas highlighted that all major U.S. societies agree screening should be available beginning at age 40 and urged formal risk assessment by age 25 to guide future screening pathways.
For women with a lifetime breast cancer risk of 20 percent or higher, experts generally categorize them as high-risk and recommend annual screening with consideration of supplemental ultrasound and MRI. “For the average-risk woman, the conversation will be more nuanced between the patient and her physician,” she said. “Depending on the individual’s preference and the recommendation of her gynecologist or primary care, the patient would screen with mammogram on an annual basis or biennially, per shared-decision making.”
Carcas noted a lack of randomized trials directly comparing mortality outcomes between annual and biennial screening, which she said leaves a gap in the evidence. “Most women who are diagnosed with breast cancer would certainly be grateful to have it diagnosed at an earlier stage, when there is less likely need for chemotherapy and other aggressive modalities of treatment,” she said.
Despite the ACP guidance, some clinicians plan to continue recommending annual mammograms and supplemental imaging when they deem it necessary, reflecting both clinical judgment and patient preference. “I remain hopeful that this new recommendation from ACP will not alter insurance coverage for patients undergoing screening, particularly in light of the differing recommendations among medical societies,” Carcas added.
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