Who: Women of all ages, but particularly women above age 45, whether insured or not.

When: On October 20, 2015, the American Cancer Society (ACS) published new guidelines for breast cancer screenings in the Journal of American Medical Association.

What: The American Cancer Society updated its screening guidelines based upon new studies and recommends breast cancer screenings for most female adults. Guidelines for women with average risk are listed below:

 

Women      Ages
	Previous	New
20 to 39	Clinical Breast Exam every 3 years.	Clinical Breast Exams and Self-Exams are not recommended. Optional. Those who choose Self-Exams should receive instruction and have techniques reviewed periodically and report any changes to a care provider.
40 to 44	Clinical Breast Exam, preferably every year.Mammogram, yearly as long as in good health.	Clinical Breast Exams and Self-Exams are not recommended. Optional. Women should have the choice to start annual screening with mammograms.
45 to 54	Clinical Breast Exam, preferably every year.Mammogram, yearly as long as in good health.	Clinical Breast Exams and Self-Exams are not recommended.Mammogram, yearly.
55 and Older	Clinical Breast Exam, preferably every year.Mammogram, yearly as long as in good health.	Clinical Breast Exams and Self-Exams are not recommended.Mammogram, every 2 years. Optional. Women should have the choice to continue annual screenings with mammograms if in good health and expected to live at least 10+ years.

 

Women at increased risk may need a different testing schedule. Increased risk includes women who:

1. Have a lifetime risk of breast cancer of 15% to 20% based on family history.

2. Have a personal history of breast cancer, ductal carcinoma in situ, lobular carcinoma in situ, atypical ductal hyperplasia, or atypical lobular hyperplasia.

Women at high risk should get an MRI with an MRI-guided breast biopsy and a mammogram every year. High risk includes women who:

1. Have a lifetime risk of breast cancer about 20% to 25% based on family history.

2. Have known BRCA1 or BRCA2 gene mutation.

3. Have a first-degree relative with the gene mutation and have not had genetic testing themselves.

4. Had radiation therapy to the chest between ages 10 to 30.

5. Have Li-Fraumeni syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes.

The ACS guidelines should NOT be confused with the 100% preventive care cancer screening requirements mandated by the ACA. USPSTF recommendations are: A (strongly recommend), B (recommend), C (no recommendation), D (recommend against) and I (insufficient evidence). Grades A and B are ACA mandates requiring 100% coverage (no patient cost sharing).

 

United States Preventive Services Task Force Breast Cancer Screening for Average Risks
Women Ages	Current (October 2015)			Draft Recommendations (2015 Review)
	Recommendation	USPSFT Grade	ACA Mandate	Recommendation	USPSTF Grade	ACA Mandate
Before 50	Mammogram  Optional. Women should have the choice to start annual screening with mammograms.	C	No	Mammogram during ages 40-49 may be helpful. Optional. Women should have the choice to start annual screening with mammograms.	C	No
50 to 74	Mammogram, every 2 years	B	Yes	Mammogram, every 2 years	B	Yes
75 and Older	Mammogram	I	No	Mammogram	I	No
All Women	Teaching self-exams	D	No	3-D mammograms Clinical breast exam	I	No
	Clinical breast exam	I	No
Dense Breasts				Screening with ultrasound, MRI, or tomosynthesis	I	No

 

Actions: Women may want to follow their preferred screening schedule with the recognition that some may not be covered by insurance. Plan sponsors should consult with their agent, broker, plan consultant, legal counsel, and/or Human Resources Department to determine if plan benefits for breast cancer screenings should follow ACS guidelines or the ACA preventive care mandates. In addition, state laws may require a different set of breast cancer screenings. Plans should also assure that their employee notifications properly inform plan participants of any benefits and any changes.

 

The information presented and contained within this article was submitted by Ronald E. Bachman, President & CEO of Healthcare Visions and a contributor to the Client Community newsletter. This information is general information only, and does not, and is not intended to constitute legal advice. You should consult your legal advisers to determine the laws and regulations impacting your business. Any opinions expressed within this document are solely the opinion of the individual author and may not reflect the opinions of Ebix or its personnel.