ACR Bulletin

Covering topics relevant to the practice of radiology

Starting a Conversation

New, more inclusive breast cancer screening guidelines seek to clarify, educate, and reach patients and their referring clinicians to get more people screened.
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I don’t think we’ve ever had guidelines coming from any radiology organization for breast cancer screening for the transgender population.

—Evelyn Carroll, MD
September 28, 2021

Breast cancer is the second leading cause of cancer deaths and the leading cause of premature death in American women. Mammography can reduce breast cancer deaths in women age 40 years and older, with a potential mortality reduction of 40% with regular screening.1 However, not all patients have access to this potentially lifesaving procedure. Minority patients and LGBTQIA+ patients have thus far been marginalized in many aspects of our health system, including cancer screening. And according to an article recently published in the JACR®, treatment advances cannot overcome the disadvantage of being diagnosed with an advanced-stage tumor, which may have been caught earlier with more regular screening.1

When Debra L. Monticciolo, MD, FACR, ACR past president and vice chair of the department of radiology and section chief of breast imaging at Baylor Scott & White Medical Center-Temple, and Stamatia V. Destounis, MD, FACR, partner and chair of clinical research and medical outcomes at Elizabeth Wende Breast Care and chief of the ACR Commission on Breast Imaging, set out to work on updating the 2017 ACR guidelines on breast cancer screening, they took a different approach. “We know that patients of color and minority patients are really at higher risk in many ways,” says Monticciolo. Minority women under the age of 50 are much more likely to be diagnosed with invasive disease and much more likely to die before the age of 50 than White women.2 “Guidelines that advise patients to wait to get screened until age 45 or 50 are a bad idea for all patients,” Monticciolo says, “but they’re really devastating for patients of color and minority patients.”

The result is updated guidelines on breast cancer screening, published jointly by the ACR and the Society of Breast Imaging (SBI), that recommend annual mammography screening beginning at age 40, which the authors note, “provides the greatest mortality reduction, diagnosis at earlier stage, better surgical options, and more effective chemotherapy.”1 To learn more about the guidelines, the Bulletin spoke with Monticciolo, Destounis, and Evelyn Carroll, MD, body imaging fellow at the Mayo Clinic in Rochester, Minn., and a future breast imaging fellow at NYU Langone Health.

What are some notable updates to the ACR/SBI guidelines for breast cancer screening?

Destounis: The ACR, in close association with the SBI and other related societies, continually updates the breast cancer screening guidelines. We want primary care physicians to know exactly what the most appropriate and up-to-date breast cancer screening guidelines are for their patients.

It’s also important to note that when we talk about breast cancer in underrepresented and underserved populations, that can include LGBTQIA+ patients — who often get overlooked in the conversation, and for whom there has been a lot of confusion over breast cancer screening guidelines (for the patients and their referring clinicians as well). Transgender patients who were assigned female at birth and have not had a mastectomy still carry the prior risk of breast cancer because they have breast tissue. The new guidelines state that annual screening is to start at age 40 for these patients. Similarly, transgender patients who were assigned male at birth and take hormones may be at higher risk for breast cancer. These patients should also begin screening at age 40.

LGBTQIA+ patients have historically faced significant barriers to getting screened. They may feel uncomfortable getting screening in a facility that may be perceived as not welcoming. In addition, their referring clinicians may not know that these patients need the screening for breast cancer.

Another population that gets overlooked is patients over 74. The U.S. Preventive Services Task Force still has no recommendations for patients 74 and over. That is also a largely ignored population. We want to make sure that these guidelines communicate that you should continue to get screened past age 74 unless you have significant comorbidities that will limit your overall life expectancy or you’re unable to undergo a needle biopsy (should something be identified on a mammogram).

Guidelines that advise patients to wait to get screened until age 45 or 50 are a bad idea for all patients, but they’re really devastating for patients of color and minority patients.

—Debra L. Monticciolo, MD, FACR

What do the new guidelines mean for patients?

Monticciolo: I hope patients will clearly see the benefits of screening and feel encouraged not to wait past the age of 40. When it comes to breast cancer screening, we sometimes hear about controversy — but there’s really no controversy about the benefits of getting screened. These benefits need to be presented clearly to patients so they can make the choice for themselves. I think patients will find the risks to be very manageable, and the benefits are outstanding. It’s not just that we can decrease breast cancer deaths by 40% — which is really significant, especially considering one in eight U.S. women will someday be diagnosed with breast cancer — but it’s an opportunity for patients who are diagnosed with a tumor to have much better options for treatment.3

We’re really trying to make clear that patients will have the best outcomes if they are screened starting at age 40 and continue to be screened regularly. Historically, the risk for people of color has been underestimated. The risks for black women in particular need to be more widely recognized by providers and the women themselves. Members of the LGBTQIA+ community have been marginalized in many ways as well. We don’t want that to be occurring in breast imaging. We want to welcome all patients.

These guidelines are based on evidence, but we need more inclusive data on breast cancer and screening for LGBTQIA+ patients. As we learn more about how breast screening can benefit all patients, we can continue to update and refine our guidelines.

Carroll: With respect to the transgender patient population, the new guidelines are excellent. I don’t think we’ve ever had guidelines coming from any radiology organization for breast cancer screening for the transgender population. Many transgender patients have no idea if they need breast screening, and most of their clinicians don’t know either.

The other issue is, will insurance cover this screening? It’s common for transgender patients to have insurance companies deny coverage for things like breast cancer screening.4 These guidelines from the experts in breast imaging will go a long way in terms of clarifying best practices and hopefully moving insurance companies in the right direction in terms of covering the screening these patients need and deserve.

How can radiologists educate PCPs and patients about these new guidelines?

Destounis: I hope these new guidelines will prompt radiologists to look at their own practice settings and ask themselves, “Are there aspects of our screening program I need to address? How can I make this better in my facility? How can I educate my staff? And how can I reach out to my PCPs with this important information?”

It’s paramount to be sensitive to different people’s needs. For example, some patients may not feel comfortable making a screening appointment in person. Does your facility have a portal that enables them to make appointments online? It’s also important to be sensitive to the workflow of how a patient will travel through your facility. Do you have privacy areas for patients? Are you equipped with sufficient options for gowns so that patients can wear what they’re most comfortable in (or bring their own gowns)? The staff needs to be educated and become familiar with things like appropriate versus inappropriate questions and making sure to use the patient’s correct pronouns and name (sometimes despite what their medical documents may say). We want all the patients who are eligible for screening to come in and get the care they need, and the healthcare provider needs to make a person feel comfortable to make that choice.

Monticciolo: I hope these guidelines make it even more clear what our charge is and encourage radiologists to be advocates for screening. We prioritized making the information easy to read and easy to relay to patients and providers. We’ve really tried to reach all the populations that would benefit from these guidelines, and I think it’s going to at least start a conversation between patients and their healthcare providers about screening — and among radiology teams about how we can do things better. We need to be mindful of inclusion. These are guidelines for all patients. We hope to bring more patients into the conversation about screening. That would be a great outcome.

Author Interviews by Cary Coryell,  publications specialist, ACR Press