This week, The American Society of Breast Surgeons (ASBrS) issued new mammogram guidelines that recommend women of average risk of breast cancer should begin annual screening mammograms starting at age 40 and that women over 25 should undergo a formal risk assessment for breast cancer. Kandace McGuire, M.D., chief of breast surgery and director of the Breast Cancer Collaborative Care Clinic at VCU Massey Cancer Center, supports these new guidelines even though they differ from those suggested by the US Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS).

In this Q&A, Dr. McGuire discusses the new guidelines and the reasons she supports them.

What are the new guidelines from ASBrS?

The ASBrS makes four primary recommendations in their new guidelines:

• Women over 25 should undergo a formal risk assessment for breast cancer.
• Women with an average risk of breast cancer should initiate yearly screening mammography at age 40.
• Women with a higher-than-average risk of breast cancer should undergo yearly screening mammography and be offered yearly supplemental imaging; this screening should be initiated at a risk-based age.
• Screening mammography should cease when life expectancy is less than 10 years.

They also provide information about personalized screening plans based on a woman’s individual breast cancer risk. Breast cancer risk is primarily determined through family history and genetic testing.

How do the ASBrS guidelines differ from the ACS and USPSTF guidelines?

The ASBrS guidelines are based on a different statistical model than those used by USPSTF and the ACS. They are calculated based on a “life-years gained” model that only accounts for survival benefits from early detection, rather than “efficiency models” used by the USPSTF and ACS that account for the cost of screening as well as risks of false positives and unnecessary treatments.

The USPSTF recommends that women of average risk begin screening at 50 years of age and stop at 74, and that women 40-49 make an individual decision based on the potential harms and benefits. The ACS recommends that women of average risk should begin annual screenings at age 45, and that women 40-44 should have the option of screening if desired.

Why do you support the ASBrS guidelines?

As a breast surgeon, I feel that we should provide clear and concise guidelines for breast screening and that we should follow the evidence to reduce breast cancer mortality. The research clearly shows that annual screening for women 40-49 years old decreases death from breast cancer by as much as 15 percent.

The ASBrS guidelines place a greater emphasis on survival and also recommend a more personalized approach to breast health based on a woman’s individual risk. These recommendations are much more in line with what our Massey breast health team practices. At VCU Massey Cancer Center, my colleagues and I have been steadfast in our opinion that yearly screening, on average, should begin at age 40 and that women should understand their personal cancer risk. This is why we have a High-Risk Breast Cancer Clinic that includes genetic counseling as a key component of breast cancer screening and managing risk of breast cancer.

We have made tremendous progress in increasing breast cancer survival and that is due, in large part, to more women being screened for breast cancer to detect it earlier, when treatment is more effective. A major concern that I share with many other doctors is that conflicting guidelines may lead to confusion among women, lower screening adherence and, ultimately, more cancers diagnosed at later stages.

How is average risk of breast cancer defined?

Average risk is a lifetime risk of breast cancer that is under 20 percent as calculated by risk models. In essence, most women are at average risk. Those at average risk have no significant family history of breast cancer and do not have one of the gene mutations or genetic syndromes associated with breast cancer. Significant family history is having two or more first-degree relatives – mother, sister, daughter, father, brother or son – with breast cancer.

Who is at higher risk for breast cancer?

Any woman with a 20 percent or greater lifetime risk of breast cancer is considered at high risk. This includes women who are carriers of a breast cancer gene mutation (such as BRCA1 or BRCA2), women who have significant family history of breast cancer, and women who had chest wall radiation between the ages of 10 to 30 and who finished the treatment at least eight years ago. Various other factors can increase a woman’s risk for breast cancer.

But it’s important to note that many women with a lifetime risk of breast cancer of less than 20 percent will ultimately be diagnosed with breast cancer. In fact, only 5-10 percent of breast cancers are due to known genetic factors. And this is why mammography screening is so important.

When and how often do you recommend that a woman should get screening mammograms if she’s at higher risk of breast cancer?

The frequency of mammography does not change for women in the high-risk group: screening mammography is recommended every year. What may change is the age at which the screening is started as well as the addition of magnetic resonance imaging (MRI). 

For women identified as having a high risk of breast cancer due to a genetic mutation, family history or prior cancer treatment, the ASBrS recommends an annual breast MRI beginning as early as age 25. At Massey, women at high risk of breast cancer are seen in our High-Risk Breast Cancer Clinic, in which they meet with a certified genetic counselor and a nurse practitioner to develop a personalized screening program, which may include MRI, and discuss the options for prophylactic treatments as preventive measures.  

How can women get more information about Massey’s breast health care or make an appointment for a mammogram or the High-Risk Breast Cancer Clinic?

To schedule a routine mammogram or to make an appointment with our High-Risk Breast Cancer Clinic, please call (804) 237-6666. For more information about Massey’s care for breast cancer and breast disorders, please visit masseycancercenter.org or call (804) 828-7999 to make an appointment.  

More information about Dr. McGuire

McGuire is a surgical oncologist specializing in breast cancer who leads VCU Massey Cancer Center’s multidisciplinary breast cancer clinic and serves as chief of breast surgery. In addition to caring for patients, she is actively involved in teaching, mentoring, research and leading clinical trials to improve patient outcomes. Her research focuses on how to minimize breast cancer intervention, non-operatively manage ductal carcinoma in situ (DCIS) and decrease age-related, racial, ethnic and socioeconomic disparities in the detection, treatment and survivorship of breast cancer. She has published more than three dozen scientific papers in peer-reviewed journals and a handful of book chapters. She has presented her research and been invited to lecture at more than 80 professional and academic conferences.