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Women in their 40s at average risk for breast cancer should talk to their health care provider about the risks and benefits of mammography before starting regular screening at that age, according to guidelines released Thursday by the American College of Obstetricians and Gynecologists.

The group had previously recommended annual mammograms starting at age 40. But the advice has changed to better incorporate input from the woman being screened, says physician Christopher Zahn, vice president of practice activities at ACOG. “A patient’s preferences and values need to be an important part” of the decision, he says.

Now the group says providers should offer the test when a woman enters her 40s, and that after a discussion, she may opt to start screening. If she doesn’t, she should start by age 50, ACOG says. Zahn says the guidance intentionally encompasses advice from other major groups.

The U.S. Preventive Services Task Force says women should start regular mammograms at 50, and that women in their 40s should make an individual decision about whether or not to screen. The American Cancer Society says screening should be offered starting at age 40, and outright recommends starting at 45. And the National Comprehensive Cancer Network, an alliance of major cancer centers, recommends starting at 40.

The question all these groups have wrestled with is how to balance the benefits and harms of mammography; their different recommendations reflect differences in how they interpreted and weighed the available data. “All three [schedules] are reasonable approaches to take,” says Zahn.

Mammography clearly saves lives for women over 50 and likely does so overall for women in their 40s, says Otis Brawley, chief medical officer at the American Cancer Society. But the benefits in those younger women are smaller, and they come at the cost of false alarms, unnecessary biopsies and overdiagnosis, when cancer that is detected and treated never would have threatened a woman’s health had it gone undiscovered. (The ACS says estimates of overdiagnosis vary widely, from 0 percent to 54 percent of breast cancers, in part depending on whether cases of ductal carcinoma in situ — abnormal cells that sometimes turn into cancer — are included.)

Once a woman starts mammography, she can be screened every one or two years, again after a discussion about the pros and cons of the different schedules, ACOG advises. The American Cancer Society recommends annual screening for women through age 54 and every other year for older women, with the option to continue annual tests, while USPSTF says every other year is sufficient and the network of cancer centers recommends annual screening.

A statistical model from the USPSTF finds that if 1,000 women are screened every other year from age 40 to 74, there will be eight fewer breast cancer deaths compared with no screening, 213 unnecessary breast biopsies and 21 overdiagnosed breast tumors. Meantime, if 1,000 women are screened every other year from 50 to 74, there will be seven fewer breast cancer deaths compared with no screening, 146 unnecessary biopsies and 19 overdiagnosed tumors.

Some women may decide that the small additional benefit doesn’t outweigh the increased risk of biopsy or possibly being treated for a cancer that didn’t need attention. There’s as yet no sure way to know which tumors are harmless and can be left alone. Others may choose differently. “There’s more of a respect for the individual person,” says Brawley about the new ACOG guidelines and the 2015 changes by his own organization. “You’re starting to hear, ‘Let the woman decide.’ “

“If a woman is told to get a mammogram starting at 40, it’s very reasonable to question that and ask, ‘Why? I’ve read that there are conflicting guidelines,’ ” says Deanna Attai, assistant clinical professor of surgery at the David Geffen School of Medicine at UCLA.

She says women should know, or ask about, the risk factors for breast cancer so they can have the screening conversation with some understanding of where they fall on the spectrum. And don’t stop the risk-reduction discussion at screening. “Ask what lifestyle or health habits can help reduce risk,” she says. (For example, research suggests exercise can cut breast cancer risk.)

On the question of when to stop routine mammograms, ACOG says screening beyond age 75 should be based on a conversation about a woman’s health status and longevity. The group also recommends against regular breast self-exams but says women should be aware of the normal feel and appearance of their breasts so they can report any changes.

Keep in mind that these recommendations are for average-risk women who are not experiencing symptoms. Many factors can increase risk, including a family history of breast or ovarian cancer and certain genetic mutations. So those women should check with their physician about when, how and how frequently they should be screened. There’s also not enough evidence to make recommendations on whether women with dense breasts should be screened differently.

Katherine Hobson is a freelance health and science writer based in Brooklyn, N.Y. She’s on Twitter: @katherinehobson

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The Senate vote on a bill to repeal and replace the Affordable Care Act is, according to conventional wisdom, one week away.

And we still don’t know what’s in the bill.

Not having concrete information is deeply uncomfortable for a journalist like me.

But for lots of people, like those who work in the insurance industry, not knowing what’s in that bill is a bigger deal. Wednesday is a deadline of sorts for these companies. If they want to sell policies next year in states that use the federal health exchange on Healthcare.gov, they have to let Health and Human Services know their intentions.

How are they dealing?

I reached out to a couple of insurance executives and asked.

Mario Schlosser is CEO of Oscar, the insurance startup that’s betting hard on the Affordable Care Act, also known as Obamacare.

Wednesday morning, Oscar announced it’s going to keep selling individual insurance in New York in 2018, and expanding its offerings in five states – New Jersey, Ohio, California, Florida and Tennessee.

It’s a bold move, considering Congress is right now considering dismantling the Affordable Care Act markets and changing the rules governing health insurance.

“When the dust settles, the individual market will be stable, and we want to be part of getting it there,” Schlosser told me.

He agreed with President Trump that the American Health Care Act, passed by the House in May, is “mean.”

“I think that bill was mean and I think that bill would lead to loss of coverage that would be bad for pretty much everybody in the system,” he said.

Schlosser said it’s crucial for the Trump administration to stabilize the current system in preparation for any changes. That includes enforcing the individual mandate, which penalizes people who don’t buy insurance, and promising to make cost-sharing payments required under the ACA that reimburse insurers for giving extra discounts to the lowest-income customers.

If they don’t, “it would kill the market overnight.” Schlosser said.

“That would be terrible for society, it would be terrible for the whole health care system, and everybody would be worse off,” he said.

I pointed out to Schlosser that his company has a direct line to the White House. His partner and co-founder is Joshua Kushner, the brother of Jared Kushner, Trump’s son-in-law and senior adviser.

Schlosser avoided talking about that relationship and suggested he didn’t know what Trump will do.

Later, I sat down for a cup of coffee at the National Press Club with Dan Hilferty, who runs Independence Blue Cross in Philadelphia and is chairman of the board of the Blue Cross Blue Shield Association. His company sells ACA health plans in the Philadelphia area and southern New Jersey.

“I’m here in DC because of what’s happening in health care,” he said. But acknowledged he doesn’t know what’s in the Senate bill, even though the Blue plans he represents as chairman of the association insure one-third of all Americans.

Hilferty said the ACA has problems, but it did manage to bring insurance coverage to about 20 million people who didn’t have it before. That’s what he’s focused on in meetings with members of Congress.

The Congressional Budget Office says the bill passed by the House would result in 23 million fewer people having insurance coverage in 10 years, compared to current law.

“So I would say let’s build a system that doesn’t that doesn’t push those 20 million people back to uninsured, “Hilferty said.

He says his company is focused on ensuring that whatever lawmakers do, they don’t make it harder for low-income people to get insurance.

“Frankly, we don’t care if it’s the ACA or the AHCA as long as it gives us the ability to cover more people, get them access to care and not lose money,” Hilferty said.

Like Schlosser, Hilferty is worried about what’s going to happen next year. His company has filed to sell ACA plans in the Philadelphia area. But if the Trump administration doesn’t commit to making cost-sharing payments or to enforcing the individual mandate that requires people to have insurance, his rates could go up a lot.

Either way, both companies are operating as if the ACA markets will be alive and functioning in 2018.

“I do think that in the end, reason and compassion will prevail in DC,” Schlosser said.

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