>> [Music] the JAMA Network.
>> Kevin Oeffinger, MD: Hello, I'm Kevin Oeffinger.
I am a family physician, and co-chaired the guideline development group
for the American Cancer Society, in developing our new,
updated guideline for breast cancer screening, for women that are at average risk
for breast cancer, and living in the United States.
I'm at Memorial Sloan Kettering Cancer Center.
And I serve as the Director of the Cancer Survivorship Center.
We spent over 18 months reviewing hundreds of studies on breast cancer screening.
And working with the Duke Evidence Synthesis Group, who conducted a systematic review.
Most importantly, we know emphatically that breast cancer screening,
with screening mammography saves lives.
It is the single, best tool that a woman has for preventing a premature death from breast cancer.
There is a consistent reduction in mortality across most study designs
for women between the ages of 40 and 69.
And there's strong, inferential evidence that women age 70 and older benefit from that.
And the American Cancer Society recommends that women around the age
of 40 begin starting their discussion with their healthcare professional.
And make a shared decision on whether
or not to start screening annually between the ages of 40 and 44.
We think that the evidence clearly shows that benefit outweighs harm, starting at age 45.
And recommend strongly that women start mammography at age 45
and continue it annually until age 54.
Then beyond that, we recommend transitioning to every-other-year.
Recognizing that as women get older, the benefit
of annual diminishes compared to every other year.
Although it never goes down to zero, there is always some benefit from annual.
We recommend that as long as a woman has a reasonable likelihood of another 10 years
of healthy life, that they continue screening.
We no long recommend having a clinical breast examination,
and rather prefer that healthcare professionals use that time to devote
to discussing the potential benefits and the potential downsides of mammography with a woman.
Or using that time for other preventative measures.
When we talk about balancing, or weighing harms and benefits,
on the benefits we're talking about the lives saved.
On the harm we're talking about a false positive, which might result in a biopsy.
Or we're talking about over-diagnosis.
The only way to 100% prevent over-diagnosis is not to be screened.
That's something none of us -- no guideline group would recommend.
About 60% of women over a 10-year period would have a false positive finding.
Most of those requiring just additional images.
About 7% to 8% of them will need a biopsy
to determine what was the abnormality on the mammogram.
And then there is also the concept of over-diagnosis.
Which the evidence review, and we concurred with,
still have such widely disparate estimates, that we really can't place an estimate.
Though we think it's around the magnitude of 2% to maybe 3%
of the women that are diagnosed with cancer.
So much smaller than what has been previously reported.
We did not feel that over-diagnosis really enters into the discussion between age 40 to 44.
There's no evidence that women that are younger, really have a higher likelihood
of having over-diagnosis than older women.
Only 65% of women in the US are having a screening mammogram
within a two-year time period.
So the American Cancer Society and others, are funding studies
to help understand what are the barriers to screening.
Whether that might be related to -- or economics that may be related
to insurance; may be related to other factors.
And then designing ways to improve or increase those screening rates.
The other area that we need better understanding, is that term over-diagnosis.
What does it mean?
When we have a woman with ductal carcinoma in situ, we simply do not have tools to determine
which of those cancers will be progressive, and which will not.
And so we need better biomarkers or other methods
of being able to identify progressive cancers.
Such that we might be able to take a more risk stratified approach in our screening.
As you see from our screening guideline, we did not use a one-size-fits-all.
We think that individualizing this,
based in part upon a woman's preferences and values is important.
As we understand more about risk, we hope that there will be a more risk-based,
or more risk-individualized approach to screening.
Again, avoiding that one-size-fits-all.
When we made these guidelines, we were very emphatic
that it is maintaining the flexibility of the American woman.
Whether she decides to start at age 40.
Or whether she continues to have annual beyond the age of 55.
And regardless of the age that she decides to stop.
And it's our hope and intent that our insurers will continue covering women age 40 and beyond,
and regardless of the interval that the woman chooses.
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