Earlier this week, the American Cancer Society (ACS) released an update to its 2003 breast cancer screening guideline. The update includes major changes in the recommendations for breast cancer screening procedures with important implications to all clinical nurses, not just those in oncology. As an organization committed to promoting quality cancer care, ONS wants to ensure that nurses are equipped with the information needed to care for and educate patients as they navigate today’s ever-evolving and dynamic healthcare system.
Understanding the Revised ACS Guideline
The new screening guideline for women with an average risk of developing breast cancer changes the age at which mammography is initiated as well the frequency they are repeated. ACS now recommends initiating annual mammography at the age of 45 and continuing with annual mammography until the age of 54, at which point women aged 55 and older should transition to mammograms every other year. ACS recommends continuing with this screening schedule so long as a woman’s health is generally well and she has a life expectancy of 10 years or longer.
In making the revised guideline, ACS systematically reviewed clinical research evaluating the effects of mammography on breast cancer mortality, life expectancy, false-positive findings, overdiagnosis, and quality adjusted life expectancy. Additionally, the organization found that clinical research is lacking to suggest the efficacy of the clinical breast exam or breast self-exam in conjunction with mammography in improving overall mortality, and was consequently eliminated from screening recommendations for women of any age with no prior breast symptoms. However, ACS clearly stated that women aged 40–44 should have the option to initiate screening and those who are at least 55 may continue to undergo annual mammography if so desired.
The revised screening guideline brings ACS closer in line with the recommendations of the United States Preventive Services Task Force (USPSTF) in regard to breast cancer screening, closing the gap between the two organizations’ recommendations. The two organizations are now in agreement that for average-risk women younger than 45, the risks of false-positive and unneeded breast biopsy associated with mammography likely outweigh the benefits, although a comparison of the two guidelines reveals that ACS is still recommending routine annual mammography at an earlier age and more frequently than USPSTF.
Key Points Regarding the ACS Guideline
The revised guideline is reflective of current evidence, and the changes are based on rigorous and systematic clinical research aimed at evaluating the efficacy of clinical breast exam and the relative benefits, limitations, and harms of mammography as well as its impact on survival outcomes. The recommendations for screening changes come only after extremely careful review of the risks associated with overdiagnosis and false-positive biopsy results in comparison with the benefits of mammography, among other considerations.
Also of note, ACS places great emphasis on the fact that the new screening guideline applies only to women of average breast cancer risk. ACS is clear that women with a higher risk of breast cancer, such as those with a family history, presence of a gene mutation that increases susceptibility (such as BRCA1/BRCA2), or a prior breast condition (such as ductal carcinoma in situ or prior chest irradiation) should begin screening at an earlier age and continue with mammography more frequently. ONS echoes this point and stresses this revised guideline is not intended for women with a known higher risk for breast cancer.
Only a woman and her healthcare provider can determine which screening guideline best applies to her. In alignment with ACS, ONS strongly encourages every woman to discuss her risk of breast cancer with her health care provider by reviewing family history, individual personal risk, and prior mammographic findings where applicable in order to determine the screening guideline most applicable to her.
Implications for Nursing Practice
Naturally, patients and families will have questions and concerns about the new guideline and strategies known to prevent breast cancer or promote early detection. Nurses can best position themselves to offer support and guidance to their patients by learning more about the new ACS screening guideline. Familiarizing yourself with the recommendations and their supporting evidence may help foster meaningful conversations with your patients as you assist them navigate screening options. ACS offers information, videos, and answers to frequently asked questions about the screening guideline for both patients and healthcare providers.
What remains of utmost importance in the ACS screening recommendation is seeking medical attention with any change in the breast. Nurses should encourage patients to have a baseline knowledge of their breasts’ normal appearance and to facilitate early intervention in the event of even a subtle change. Some patients may still want to perform self-exams, and nurses play a vital role in educating patients about the procedure.
The introduction of the new guideline underlines the importance of encouraging patients to discuss screening and personal breast cancer risk with their healthcare providers to make individualized decisions in the best interest of their health. Nurses are key in encouraging and initiating those conversations. There are competing screening guidelines outside of ACS and USPSTF as well extenuating circumstances affecting personal risk to consider. Patients and families cannot be expected to interpret and implement the guidelines alone.
ONS Will Keep You Up to Date
As the ACS guideline is further disseminated and implemented in preventive medicine, ONS will continue to equip nurses collaborating with healthcare providers and patients with the needed resources to promote quality care. We will remain committed to incorporating all current evidence into resources and tools for nurses caring for patients in all stages of the cancer disease continuum: prevention through end-of-life care.