Many Women Begin Receiving Mammograms Earlier Than Recommended

While contentious debate continues about when women should begin undergoing routine mammograms -- whether at age 40, by age 45 or starting at age 50 -- an altogether different reality unfolds in many doctors' offices that undercuts all guidelines.

Nearly a third of women report undergoing a mammogram before age 40, which is earlier than any medical organization recommends starting routine breast cancer screening, says Robert Smith, vice president of cancer screening at the American Cancer Society. Approximately 14.5 percent of women ages 35 to 39 say they received a mammogram in the past year, and 31.5 percent in that age group report having ever received a mammogram, according to a new ACS analysis of data collected by the U.S. Census Bureau for the 2013 National Health Interview Survey, which captures information on a range of health topics. The ACS shared the previously unpublished data with U.S.News. While it's unknown if the one-third of women who reported undergoing early mammograms were doing so as a screening measure versus for the purposes of diagnosis, like, after discovering a lump, Smith suspects the majority probably underwent mammograms for screening purposes. (The timing of mammography for diagnostic purposes is not being debated.)

These data suggest that many women are getting screened according to guidelines halted nearly a quarter century ago in 1992, when the ACS stopped encouraging women to get so-called "baseline mammograms" between ages 35 and 39. "The idea was women would get one mammogram in that period that could be used as a comparison film when they started regular screening at the age of 40," Smith says. Radiologists could check the baseline film against the most recent mammogram to see what had changed and better determine whether a woman might have cancer. At least that was the idea.

But as with many recommendations initially made in the 1970s and early 1980s, Smith says the guidelines were based on expert opinion versus rigorous study. As it turned out, the films often went unused, he says, and because of the low risk of cancer for that age group, the high likelihood of false positives and unnecessary follow-up procedures, like biopsies, as well as the potential for needless treatment that could expose women to harm, that recommendation was dropped.

"It's startling sometimes how long it takes to change behavior. ... There are a lot of things we do not recommend and actually aggressively recommend against, and doctors continue to do them," Smith says. He adds that it's not known whether OB-GYNS, whom many women under age 40 see as their adhoc primary care provider, or traditional primary care doctors are more commonly recommending routine mammograms for this age group. But what's certain is that the ACS and other major organizations that have issued guidelines for breast cancer screening, including the American Congress of Obstetricians and Gynecologists, recommend against the practice.

Nor is there an active debate in the medical community regarding whether baseline mammograms should still be routinely performed in women ages 35 to 40, says Dr. Mary Rosser, a spokeswoman for ACOG. There's "no good information or data" that supports providing baseline mammograms for women, says Rosser, an OB-GYN at Montefiore Medical Center in New York City. She speculates -- as Smith does -- that, "Doctors and providers get comfortable with what they're doing. People are still doing Pap smears every year," she says, despite current recommendations from leading medical organizations, including the ACS, which women ages 21 to 65 have these done every three years if results are normal.

Experts say patients, too -- having grown up in a culture that embraces early detection, including regular mammograms -- may request to begin mammograms earlier than recommended. Insurers typically cover the mammograms, as they do Pap smears, for women who choose to continue getting those annually.

ACOG currently recommends that women begin routine breast cancer screening at age 40 and then undergo a mammogram annually thereafter. The ACS revised its recommendations in October and now advises that women ages 40 to 44 have the choice to start breast cancer screening if they wish -- suggesting they consider the risks as well as potential benefits -- and that all women should begin annual mammograms by age 45, continuing through age 54, then switching to every other year starting at age 55. The U.S. Preventive Services Task Force, an independent group of experts that makes recommendations on preventive care, advises women to begin routine breast cancer screening at age 50, and continue getting mammograms every other year through age 74.

"Mammography is an important tool in the fight against breast cancer," says Dr. Kirsten Bibbins-Domingo, Task Force co-vice chair, in email. Bibbins-Domingo, a professor of medicine, epidemiology and biostatistics at the University of California--San Francisco, and other experts point out that age is a major factor in how useful that tool is among individual patients.

While the Task Force's recommendations don't specifically address baseline mammograms, she notes: "Breast cancer is extremely uncommon in women under the age of 40 years, occurring in about 1 in 10,000 women. As such, there have been no trials, and there is very little evidence evaluating screening mammography in average-risk women younger than 40 years of age." And she reiterates: "At the present time, there are no professional organizations that recommend routine mammography screening in average-risk women under the age of 40 years." In addition, research finds that because younger women tend to have higher breast density, mammography can be even less accurate and useful for early detection in this age group, since doctors reading mammograms evaluate breast density when looking for cancer.

However, experts say some women should still talk to their doctor about starting breast cancer screening before age 40, whether through mammography or MRI. That includes those at higher risk for breast cancer, such as women with a family history of the disease, individuals with a BRCA1 or BRCA2 gene mutation, which are known to increase a women's risk of developing breast cancer, or those who've had radiation therapy to the chest between ages 10 and 30 years, according to the ACS.

Smith notes that mammography may also be used as a diagnostic tool for women of any age suspected to have breast cancer. Potential signs or symptoms of breast cancer include "a thickening in the breast ... a lump that she can feel, some local pain although that's not very common, a change in the appearance of her nipple or nipple discharge," he says.

A breast cancer survivor herself, Rosser adds that it's important for women to be aware of changes in their own bodies. "We also say clinical breast exams should start when women are 20 years of age," she says, and that the physical exam should be completed by a woman's doctor annually thereafter.

Rosser adds that it's still important to treat the patient as an individual -- even if that means sometimes deviating from guidelines. "If I have explained all the evidence thoroughly for why we should start screening at age 40, but you have a 37- [or] 38-year-old that's anxious [though] she has no risk factors," Rosser says she still takes heed. "Most women [who] have invasive breast cancer do not have unique identifiable risk factors. So, the incidence of breast cancer does increase with advancing age. [But] if I have done all of this discussion and counseling and a patient still wants a baseline mammogram, then I'm going to do that."

Michael Schroeder is a health editor at U.S. News. You can follow him on Twitter or email him at mschroeder@usnews.com.