As research and technology continue to shape the field of health care, experts in prevention and evidence-based medicine have been able to provide clearer guidance on screening tests. As such, the U.S. Preventive Services Task Force (USPTF) initially published a breast cancer screening final recommendation statement in 1996, which was later revised in 2002, 2009, and 2016.
While the original recommendation suggested that a woman's decision to begin mammography screening prior to age 50 should be an individual one, USPTF recently released a new draft recommendation suggesting that all women get screened for breast cancer every other year starting at age 40. Given the opportunity to review this proposed draft, several practitioners have affirmed their agreement with the updated recommendation but indicated additional guidance is needed.
According to the USPTF, the newly drafted screening recommendation applies to women at average risk of breast cancer, potentially resulting in "19 percent more lives being saved." Included in this patient population are those with a family history of breast cancer and patients known to be at risk of other factors (i.e., dense breasts). However, the proposed recommendation does not apply to those with "a personal history of breast cancer, who are at very high risk of breast cancer due to certain genetic markers or a history of high-dose radiation therapy to their chest at a young age, or who have had a high-risk lesion on previous biopsies," the draft stated.
In response to these updates, Elizabeth H. Dibble, MD, Assistant Professor of Diagnostic Imaging at the Warren Alpert Medical School of Brown University and a radiologist trained in breast imaging, nuclear medicine, and molecular imaging (with expertise in breast cancer imaging), confirmed that she believes women should be getting screened through mammography by age 40 at the latest.
She explained that some women may require earlier or additional screening depending on their individual risk factors for developing breast cancer. Dibble added that women at average risk for breast cancer should not only begin screening at age 40 (and not 50 as in prior USPSTF guidelines), but they should get screened with mammography every year-not every other year as the newly proposed USPSTF guidelines recommend.
Clearer Guidelines Needed
While there is no downside to women making individual decisions about their own health care, Dibble expressed that the prior USPSTF recommendations have historically conflicted with other breast cancer expert consensus guidelines on the age of initial screening. This has made it challenging for women to make informed choices using the best available evidence, she noted.
"One in eight women is diagnosed with breast cancer in her lifetime, and three-quarters of women diagnosed with breast cancer have no family history of breast cancer. Women without any known risk factors for breast cancer should begin screening mammography at age 40," Dibble affirmed. "Every woman should [also] undergo a breast cancer risk assessment by the age of 25 to determine whether she needs additional or earlier screening based on her individual risk for developing breast cancer."
Amy K. Patel, MD, Medical Director of The Breast Care Center at Liberty Hospital, Assistant Professor of Radiology at UMKC School of Medicine, and a board-certified radiologist who specializes in breast imaging, also believes the USPSTF has not gone far enough in terms of its recommendations. She says a potential downside to the prior recommendation is that patients and providers have not been able to fully understand when to begin screening and if supplemental screening is warranted-particularly if a patient has above-average risk and/or has a history of dense breasts.
"This lack of understanding can be attributed to conflicting recommendations, which often cause confusion not just amongst the public, but amongst the medical community who [is] at the helm of referral decision-making for appropriate imaging," Patel said. "If a woman is not screened appropriately, this could mean detecting breast cancer at a later stage, which leads to more invasive treatment and a decreased survival probability."
Thus, Patel believes it's time that medical experts clear the confusion repeatedly caused by differences in recommendations. This means getting on the same page and recommending annual screening mammography in average-risk women beginning at age 40. For patients to have autonomy in their medical decision-making, they must be met with reliable information and education.
"There are vast disparities in health literacy and misinformation abounds, which complicates the decision-making process," agreed Lauren A. Green, MD, a radiologist at Rush University Medical Center and Medical Advisor at the Dr. Susan Love Foundation for Breast Cancer Research. "Some argue that only women with breast cancer risk factors, such as genetic mutations and strong family histories, should undergo screening in their 40s, but unfortunately, most women diagnosed with breast cancer do not have identifiable risk factors (at least not at this point in history). The best solution is for women to therefore screen early and often."
Green expressed her belief that the recommendations are a step in the right direction, but they are still inadequate. She agreed that most patients should start screening at age 40, as nearly 20 percent of breast cancers are diagnosed in patients in their 40s. Therefore, Green attributes the previous recommendation to start at age 50 as having contributed to delayed breast cancer diagnoses in too many patients.
Early Detection, Risk Assessment
Green explained that beginning mammogram screening at age 50 not only leads to increased breast cancer mortality, but also higher morbidity and decreased quality of life. She noted that patients diagnosed early often have the option of less aggressive treatments. Alternatively, more aggressive treatments are associated with more significant risks of side effects and complications that can be life-altering.
"We know that one-sixth of breast cancers are diagnosed in women from the ages of 40 to 49," Patel said. "We must push to have all groups be on the same page to recommend annual screening mammography beginning at age 40 in average-risk women and risk assess all women no later than age 25 to see if they warrant earlier and heightened imaging surveillance."
Patel shared that, at her practice, the team has been identifying younger women who qualify for the appropriate imaging surveillance as more women undergo risk assessment. The practice has seen advanced breast cancers in women as young as their late 20s/early 30s, which is why she believes the guidelines for risk assessment are so imperative. Their importance also stems from increasing evidence demonstrating that Black and other minority women are being diagnosed and dying from breast cancer prior to age 50 (or even age 40) more often than White women.
"Women in their 40s can and do develop aggressive, life-threatening breast cancers. The goal of screening mammography is to detect breast cancers when they are small and more easily treatable and curable," Dibble added. "Waiting for breast cancer to grow large enough to be felt, or waiting an extra year between mammograms, increases the chance that the cancer spreads and becomes difficult or impossible to cure. Annual screening starting at age 40 saves the most lives."
Green also shared that recommending screening every other year is especially inadequate in populations, such as young patients and Black women, who more frequently develop aggressive types of cancer and need to be diagnosed at as early a stage as possible. She said screening every year allows for the best potential outcomes and a patient's degree of lifetime breast cancer risk is the most important factor in determining if a patient should start screening mammography before the age of 40.
"Annual screening also allows for earlier detection, particularly of more aggressive, faster-growing cancers. These cancers tend to occur more often in certain populations, such as Black women," Green stated. "Young patients who develop breast cancer before the age of 50 also frequently have more aggressive cancers. It is essential to find these types of cancers early in order to allow for the best possible outcomes."
Patel believes the previous USPSTF recommendations have especially fallen short in emphasizing this point. She stresses that multiple groups (including the American Association for Cancer Research, Society of Breast Imaging, and American Cancer Society) are in agreement that the most lives and life years saved are associated with an annual approach to screening beginning at age 40. She noted that previous recommendations from the USPSTF did not include more recent data or diverse data presenting the increasing evidence that Black and other minority women are diagnosed and die from breast cancer earlier than age 50.
"While there is no trial data that compares annual versus biennial screening, the task force evaluated modeling studies, which assist us in understanding and predicting outcomes over time and across populations," Patel said. "After a comprehensive analysis, the latest science continues to demonstrate that, when one balances [the] lives saved against harms such as unnecessary follow-ups and treatment, women benefit more when screening is performed every year."
In her clinical experience, Dibble has not seen many referring providers send their patients for mammograms before the age of 40-unless they are breast specialists very well-versed in high-risk screening paradigms. In contrast, she has seen dozens of patients every year who begin screening mammography too late.
"The biggest risks from screening are that patients will need to come back for a few additional pictures and, more rarely, patients may need a needle biopsy of something that turns out not to be cancer," Dibble said. "Patients overwhelmingly tell me they would rather be safe than sorry, and [that] this is a small price to pay compared to the risk of a late diagnosis of breast cancer."
Recommendations Moving Forward
In an effort to keep recommendations as current as possible, the USPSTF stated that the updated draft recommendation statement must follow a multi-step process, including a review of evidence. Prior to any official approval of this draft recommendation, the task force noted that more research regarding women with dense breasts may require additional screening, such as with breast ultrasound or MRI.
"The task force also found there was not enough evidence to make a recommendation for or against screening in women ages 75 and older. We in the field of breast imaging call for more research on this important topic and, in the absence of evidence, the decision for screening in this age demographic should be based on individual health needs and health history (i.e., screening should continue unless severe comorbidities limit life expectancy)," Patel said.
She noted that the task force gave the supplemental screening part an "I" rating, meaning there is insufficient evidence to make a recommendation, which she believes is also "deeply concerning." Patel noted this is because the ones who fall most victim to this rating are Black women and younger women who need earlier imaging surveillance. This then leads to insurance coverage implications, which at this time vary widely per state.
"There seems to be a push for more individualized screening and the use of supplemental screening modalities, such as MRI, automated breast ultrasound, and contrast-enhanced mammography. Not all patients are the same," Green added. "Some have dense breast tissue. Some are at increased risk for breast cancer. Some may have a personal history of breast cancer or other risk factors."
To this point, she referenced a 2021 call by the ACR for enhanced screening attention in Black, transgender, and other often-overlooked and underserved populations as greater breast cancer-related risks have been identified. She noted that a diverse patient population should lead practitioners to aspire to tailor supplemental screening regimens based on an individual's medical history and attributes. She also suggested that the USPSTF update its guidelines every 5 years or earlier if new compelling data arises.
"[Overall,] health care changes rapidly. Expert consensus guidelines should be continuously evaluated and reviewed by experts to ensure that they are as up-to-date as possible," Dibble concluded.
Lindsey Nolen is a contributing writer.