Recommendations from European Breast Guidelines

Should annual vs. biennial mammography screening be used for early detection of breast cancer in women aged 45 to 49?

Recommendation

For asymptomatic women aged 45 to 49 with an average risk of breast cancer, the ECIBC's Guidelines Development Group (GDG) suggests against annual mammography screening over biennial mammography screening in the context of an organised screening programme (conditional recommendation, very low certainty in the evidence)

Recommendation strength

  •   Strong recommendation against the intervention
  • Conditional recommendation against the intervention
  •   Conditional recommendation for either the intervention or the comparison
  •   Conditional recommendation for the intervention
  •   Strong recommendation for the intervention

A recommendation can be strong or conditional.

When a recommendation is strong, most women will want to follow it. When a recommendation is conditional, the majority of women want to follow it but may need more discussion with their healthcare professional first.

Subgroup

The GDG noted that women with a strong family history may be considered for more frequent screening within screening programmes (United Kingdom). Other countries do more intensive surveillance for high-risk women.

Justification

Overall justification

The conditional recommendation against annual screening was the result of the health effects that probably favour biennial screening, although the certainty of the evidence was very low.

Considerations

Implementation

 
1. The GDG notes that there is variability in the acceptability between countries and that the current practice will impact the ease of implementation and the acceptability of this intervention to key stakeholders.
 
2. The GDG agreed that the possibility of using other imaging techniques in this subgroup of women may be relevant to consider.

Monitoring and Evaluation

Careful monitoring of interval cancer rates in this age group is warranted.

Research Priorities

1. The GDG agreed that more research on the effectiveness of the different screening intervals, comparative studies, would be helpful due to the very low certainty of the evidence.

2. Less information is available for certain outcomes in this age group (e.g. interval cancer).

3. The GDG notes that cost-effectiveness research would be helpful to further assess this screening interval in women aged 45 to 49.

4. The GDG notes that there is a lack of research on other imaging modalities between screening intervals with mammography for women of this age-group.

5. There was discussion in the GDG whether women with dense breasts in this age group should be screened at different intervals.

6. The GDG felt that increased cost effectiveness data, having more contextualised costs and cost-effectiveness analysis and from other settings would be helpful for future recommendations; this included checking the consistency of cost-effectiveness models with new research from trials on breast cancer screening and natural history of breast cancer disease. Also many member states have cost analysis but they are in the grey literature and not publicly available, and this should be shared with the scientific community. This priority may apply to all other screening interval recommendations.

Evidence

Download the evidence profile

Assessment

Background

Breast cancer is the second most common cancer in the world and the most frequent cancer among women with an estimated 1.67 million new cancer cases diagnosed in 2012 (25% of all cancers)(Ferlay et al., 2013). In 2018 in Europe, it is estimated that 41,449 women between the ages of 45 and 49 will be diagnosed with breast cancer and 5,680 will die (Ferlay, 2018). Mammography screening has both potential benefits and harms. The Guidelines Development Group has conditionally recommended against screening in women between the ages of 40 and 44, but conditionally for screening for women between the ages of 45 and 49.
Debate about the recommended interval for screening with mammography remains due to the theoretical advantage of earlier diagnosis but a potential increase in harms with shorter screening intervals. For example, the USPSTF recommended to individualise the decision of screening (Siu, 2016) in women aged 40 to 49 years, while the ACS recommended annual screening between the ages of 45 and 54 (Myers, 2015).

Management of Conflicts of Interest (CoI): CoIs for all Guidelines Development Group (GDG) members were assessed and managed by the Joint Research Centre (JRC) following an established procedure in line with European Commission rules. GDG member participation in the development of the recommendations was restricted, according to CoI disclosure. Consequently, for this particular question, the following GDG members were recused from voting: Roberto d'Amico and Chris de Wolf. Miranda Langendam, as external expert, was also not allowed to vote, according to the ECIBC rules of procedure.
For more information please visit http://ecibc.jrc.ec.europa.eu/gdg-documents

Is the problem a priority?
Yes *
* Possible answers: ( No , Probably no , Probably yes , Yes , Varies , Don't know )
Research Evidence
Breast cancer is the second most common cancer in the world and, by far, the most frequent cancer among women with an estimated 1.67 million new cancer cases diagnosed in 2012 (25% of all cancers) (Ferlay et al., 2013). Breast cancer ranks as the fifth cause of death from cancer overall (522,000 deaths) and it is the second cause of cancer death in developed regions (198,000 deaths, 15.4%) after lung cancer. In 2018 in, Europe, it is estimated that 41,449 women between the ages of 45 and 49 will be diagnosed with breast cancer and 5,680 will die (Ferlay, 2018). Mammography screening has both potential benefits and harms. The Guidelines Development Group has conditionally recommended against screening in women between the ages of 40 and 44 but conditionally for screening for women between the ages of 45 and 49. The balance between benefits and harms for the different intervals is still debatable, with recommended periodicity varying from annual to triennial for women from 50 to 59 years old. In the group of women aged between 45 to 49, the amount of evidence is even more scarce and the topic is controversial.
Additional Considerations

This question was prioritised by the GDG.

How substantial are the desirable anticipated effects?
Small *
* Possible answers: ( Trivial , Small , Moderate , Large , Varies , Don't know )
Research Evidence