New guidance issued on breast cancer screening, hormone therapy

The American College of Obstetricians and Gynecologists (ACOG) released a practice bulletin last week on screening for breast cancer in average-risk women.

The bulletin updates ACOG's 2011 guidance on this issue and emphasizes shared decision-making between patient and clinician when considering screening mammography. Level A recommendations, defined as those based on good and consistent scientific evidence, are as follows:

• Screening mammography should be offered to women at average risk of breast cancer starting at age 40 years. This group should not start screening mammography earlier than age 40 years. Average-risk women who don't start screening in their 40s should begin screening mammography by no later than age 50 years. A shared decision-making process should be used to decide about the age to begin mammography screening, and the discussion should include information on potential benefits and harms.
• Women at average risk for breast cancer should undergo screening mammography every one or two years based on an informed, shared decision-making process, including a discussion of the benefits and harms of annual and biennial screening and patient values and preferences. ACOG stated that biennial screening mammography, particularly after age 55 years, is a reasonable option to reduce harms, as long as patients are informed during counseling that decreased screening leads to some reduction in benefits.
• Screening mammography should continue in women at average risk for breast cancer until at least age 75 years.

ACOG also noted that breast self-examination is not recommended in women at average risk for breast cancer because of risk for harm from false-positive test results and a lack of evidence of benefit. This is a Level B recommendation, based on limited or inconsistent scientific evidence.

In a Level C recommendation, defined as a recommendation based primarily on consensus or expert opinion, ACOG noted that average-risk women should be counseled about breast self-awareness, defined as a woman's awareness of the normal appearance and feel of her breasts, and should be encouraged to notify their clinician if they notice a change. Another Level C recommendation noted that age alone should not be used as a basis to continue or discontinue screening and that the decision to discontinue screening mammography after age 75 years should be “based on a shared decision making process informed by the woman's health status and longevity.”

The complete practice bulletin, including all recommendations, is available free of charge online.

Separately, the North American Menopause Society released a position statement last week on the use of hormone therapy for menopause-related symptoms.

The statement updates the society's 2012 statement on this topic and takes into account additional long-term randomized clinical trials and observational studies that have been published in the interim. Level I recommendations, or those based on good and consistent scientific evidence, include the following:

• Hormone therapy is the most effective treatment for vasomotor symptoms and the genitourinary syndrome of menopause and has been shown to prevent bone loss and fractures.
• The risk/benefit ratio is most likely best for symptomatic women who start hormone therapy before age 60 years or those who are within 10 years of onset of menopause.
• Hormone therapy is recommended as first-line treatment for women without contraindications who have bothersome vasomotor symptoms. It may be considered as a primary therapy for preventing bone loss and fractures in postmenopausal women at higher risk for fractures and osteoporosis, especially those who are younger than age 60 years or are within 10 years of menopause onset. Bone-specific medications, each of which has potential risks and benefits, are also options.
• For isolated genitourinary symptoms caused by menopause, low-dose vaginal estrogen therapy is preferred as first-line medical therapy over systemic therapy.
• Discussions about the risks and benefits of hormone therapy should address heart disease and all-cause mortality, especially the fact that hormone therapy reduces risk if started before age 60 years or within 10 years of menopause onset and increases it if started further from onset or in older women.

The full position statement is available free of charge online and was published by Menopause on June 20.