Older women, women with serious health problems, and those at increased risk for breast cancer will get more specific advice about breast cancer screening under updated guidelines released Wednesday night by the American Cancer Society.

The guidelines advise doctors and patients on the proper intervals for mammograms and breast exams in an effort to detect breast cancer early, when it is most likely to be treatable. They are published in the journal CA: A Cancer Journal for Clinicians (Vol. 53, No. 3: 141-169).

Despite recent controversies over its usefulness, especially in women under age 50, mammography is still considered to be the gold standard for early detection of breast cancer, experts said.

“Women and doctors need to understand that we are more confident than ever in the benefits of mammography,” said Debbie Saslow, PhD, director of breast and gynecologic cancers for the American Cancer Society. “The benefit is particularly clear for women in their 40s. We have much more evidence, and much more convincing evidence, that those women benefit.”

RESOURCES: Breast cancer guidelines in CA: A Cancer Journal for Clinicians What Has Changed And Why Role Of Breast Self-Examination Changes In Guidelines

For this reason, the basic screening recommendation remains unchanged. Women are still advised to get a mammogram every year, starting at age 40.

But the new guidelines put more emphasis on educating women – especially those at increased risk for breast cancer -- about the benefits and limits of mammography and other screening methods.

Under the old guidelines, for instance, women with a higher than average risk for breast cancer (those who have already had the disease, or who have a family history of it, or with a genetic mutation that greatly increases their risk of developing it) were advised to discuss screening with their doctor.

The updated guidelines are more specific about who is at increased risk and their options for screening. Now, women and their doctors are encouraged to discuss the possibility of beginning screening earlier (at age 30, or in rare cases even younger). Another option might be to consider screening with breast ultrasound or MRI in addition to their regular mammogram.

“If you know you are at increased risk, there is no question that the way you approach screening should be different,” said Amy Langer, executive director of the National Alliance of Breast Cancer Organizations (NABCO), and an 18-year survivor of breast cancer.

Older women, too, are now provided with more specific advice about screening.

The previous guidelines did not address the issue of how long a woman should continue to get screened for breast cancer. The risk of getting the disease increases with age, but many older women also have serious health conditions that make screening less practical and beneficial for them.

“As long as a woman is in good health, she should continue getting routine mammograms,” Langer said.

But women with chronic health problems, serious illnesses, or a short life expectancy may not get the same benefit from screening as healthy women because they may not be able to pursue treatment if breast cancer is found, Langer noted.

The updated guidelines urge doctors and women to consider these issues when deciding whether to continue mammograms as a woman ages. However, the guidelines note that age alone is not a reason to stop screening.

The updated guidelines also have clarified the role of the clinical breast examination (a physical exam of the breasts by a health care professional) and breast self-examination (BSE) to focus on general breast health, as opposed to cancer detection.

Although these physical exams are important, their role in detecting cancer early is limited, Saslow said, because by the time a lump can be felt, “it’s likely to have been there for quite some time, and the longer it’s been there undetected, the more chance it’s had to grow and spread.”

Still, mammograms aren’t perfect, Langer noted, and a health care professional may notice an abnormality in the breast that would not be detected by a mammogram – an asymmetry, for instance – but could indicate disease.

The updated guidelines recommend women get a clinical breast exam as part of their regular physical check up (about every three years for women 20-39, and yearly for women 40 and older), and encourage them to use the opportunity to talk with their healthcare provider about breast health: what’s normal and what isn’t, breast cancer risk factors, early detection testing, and the importance of bringing any changes to a doctor’s attention quickly.

Recommendations for breast self-examination have been updated as well. Previously, the guidelines recommended women perform breast self-exam every month. Now, they recommend that, beginning in their 20’s, women should be told about the benefits and limitations of BSE, and that it is acceptable for women to choose not to do BSE, or to do it occasionally. The importance of promptly reporting changes to a physician is emphasized.

The reason for this change is that research has shown that BSE plays a very small role in detecting breast cancer compared with self awareness. Often, women who do detect their own breast cancer find it outside of a structured breast self-exam; they may detect a lump while showering or getting dressed.

That’s why the emphasis is on self awareness, Saslow said. “When it comes to self-detection, we want women to be aware of what their breasts normally feel like and look like, and to be attuned to any change, and to bring any change to the attention of their doctor right away.”

This is the first major change in the breast cancer screening guidelines since 1997, when the Society began recommending annual mammograms for all women starting at age 40.

All American Cancer Society screening guidelines are revised regularly, typically every five years, to take account of new scientific findings and developments.

This revision of the breast cancer screening guidelines also includes information about new and emerging screening technologies.

The updated guidelines recognize that mammography is still the gold standard for screening, and new technologies must equal or exceed its performance in order to be recommended as screening tools. There are a number of technologies, such as breast ultrasound and MRI (magnetic resonance imaging) that, when used with mammography, may enhance the effectiveness of screening and diagnosis. However, none of these used alone is appropriate for breast cancer screening. Ongoing and future clinical trials will allow for further study and development of new technologies.