ACOG also deems it likely that insurance coverage may be affected for some women.
“Fellows should be aware that the new USPSTF recommendations against routine screening mammography for women aged 40–49 (a grade C recommendation) has implications for insurance coverage, as some insurers will cover only preventive services rated as an ‘A’ or a ‘B’ by the USPSTF. Fellows should counsel their patients that insurance coverage for ‘routine screening’ mammography may become variable and that patients should address this question with their insurers. These recommendations do not apply to high-risk women or patients with clinical findings, and they should be managed accordingly.”5
7. What should you tell your patients?
With all the media attention devoted to the change in guidelines, it’s little surprise that patients are asking questions.
“Patients are aware of the USPSTF report,” said Dr. Barbieri. “They are largely ignoring the recommendations and sticking with annual mammograms.”
“I think, as always, women are looking to their ObGyn for guidance,” added Dr. Kaunitz.
So what are these clinicians telling patients about mammography screening?
As he was to begin with, Dr. Kaunitz is acquiescent if patients prefer to defer mammography screening to their 50s.
“Because it seems that insurance coverage, over the short term, is unlikely to restrict current access to mammograms,” said Dr. Kaunitz, “my evolving philosophy is that the new USPSTF guidelines, along with ACOG and other existing guidelines, give ObGyns and their patients permission to:
- proceed or not proceed with mammograms for women in their 40s, with the decision based on issues such as patient preference, family history of breast cancer, and body mass index (BMI)
- be flexible regarding 1- to 2-year screening intervals among women in their 50s, 60s, and 70s, with the decision based on issues such as patient preference, use or non-use of estrogen-progestin hormone therapy, family history of breast cancer, and BMI.”
Dr. Barbieri believes some effort to integrate the ACOG and USPSTF recommendations is called for. “Accordingly,” he said, “I suggest the following:
I suggest actively recommending biennial mammography for women 40 to 75 years old. Offer annual mammography to women 40 to 75 years old if they prefer that option.
ROBERT L. BARBIERI, MD
- Actively recommend biennial mammography for women 40 to 75 years old. Offer annual mammography to women 40 to 75 years old if they prefer that option.
- Aggressively search for high-risk women, with high risk defined as a lifetime risk of breast cancer exceeding 15%. Among the variables contributing to high-risk status are a history of thoracic radiotherapy, a strong family history of breast cancer, and BRCA mutation. For these women, I would recommend annual mammography and biennial MRI of the breasts.
- Perform annual or biennial clinical breast exam.
- Obtain imaging for any woman who has a palpable breast lump, and resect or biopsy the lump even if that imaging is negative.”