Change in guidance: Women should be screened for breast cancer starting at 40
The U.S. Preventive Services Task Force has posted a draft recommendation statement on screening for breast cancer. The Task Force now recommends that all women get screened for breast cancer every two years starting at age 40.
While U.S. Preventive Services Task Force (USPSTF) has consistently recognized the lifesaving value of mammography, the USPSTF previously recommended that women in their 40s make an individual decision about when to start screening based on their health history and preferences. In this new recommendation, the USPSTF now recommends that all women get screened starting at age 40. This change could result in 19% more lives being saved.
“New and more inclusive science about breast cancer in people younger than 50 has enabled us to expand our prior recommendation and encourage all women to get screened every other year starting at age 40,” says USPSTF immediate past chair Carol Mangione, M.D., M.S.P.H. “This new recommendation will help save lives and prevent more women from dying due to breast cancer.”
Black women are 40 percent more likely to die of breast cancer than White women and too often get deadly cancers at younger ages. The USPSTF recognizes this racial disparity and is calling for more research to understand the underlying causes and what can be done to eliminate it.
There are many key areas where more research is essential. The USPSTF says they need to know how best to address the health disparities faced by Black, Hispanic, Latina, Asian, Native American, and Alaska Native women, particularly how to ensure equitable follow-up after screening. Timely and effective treatment for breast cancer has the potential to save more lives for people experiencing disparities related to racism, lack of access to care in rural communities, low income, and other factors. More research is also needed on the benefits and harms of screening and treatment in women ages 75 and older.
Application
This draft recommendation applies to women at average risk of breast cancer. This includes people with a family history of breast cancer and people who have other risk factors, such as having dense breasts. It does not apply to people who have 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.
“We know that women with dense breasts are at higher risk of breast cancer and, unfortunately, mammograms do not work as well for them,” says USPSTF member John Wong, M.D. “What we don’t know yet, and what we are urgently calling for more research on, is whether and how additional screening for women with dense breasts might be helpful, including through ultrasound, breast MRIs, or something else.”
More lives could be saved
The USPSTF says the shift to regular mammograms at age 40 could save 19% more lives. Breast cancer makes up nearly 30% of new cancers in U.S. women each year, and it’s estimated that 1 in 8 women will develop breast cancer in the course of their lives. The median age for diagnosis across all women is 62, but that can vary by racial group.
Other organizations have long pushed for regular mammograms beginning at age 40 including, American College of Radiology, the American Society of Breast Surgeons, and the American College of Obstetricians and Gynecologists. But the USPSTF is the official body that many primary care doctors follow for preventive testing.
The guidelines were due to become official after the USPSTF reviews feedback during the public comment period that ends 5 June.
American College of Radiology and Society of Breast Imaging statement
The American College of Radiology (ACR) and Society of Breast Imaging (SBI) has urged the USPSTF to go further to recommend annual mammography screening for all average-risk women ages 40 and older.
The USPSTF , ACR, SBI, American Cancer Society and others all agree that the most lives are saved with this annual approach. Medical experts should clear the confusion caused by differing recommendations and agree to recommend yearly mammography for average-risk women starting at age 40, says the ACR and SBI. The ACR and SBI also recommend that all women have a risk assessment by age 25, as called for in new ACR/SBI guidelines for high-risk women < https://www.jacr.org/pb-assets/Health Advance/journals/jacr/Monticciolo_ACRHiRiskScr-1683132562870.pdf > and discuss with their doctor whether earlier screening with mammography and/or MRI is needed.
Transgender persons
Transgender persons can be at increased risk for breast cancer due to hormone use and surgical history. Biological females transitioning to male who do not undergo mastectomy remain at their previous risk for breast cancer and should continue to be screened as such.
As outlined in current (2021) ACR/SBI recommendations for average-risk women, due to hormone use, biological males transitioning to female are at increased risk for breast cancer compared to other males and should speak with their doctor about their breast cancer risk.
The societies also recommend that women continue screening past age 74, unless severe comorbidities limit life expectancy.
Susan G. Komen comments on draft recommendations
Commenting on the USPSTF draft recommendations that women of average breast cancer risk should begin biennial screening mammography at age 40, rather than at age 50, Susan G. Komen, a leading breast cancer organization, said: “We are pleased to see that the USPSTF has taken into account more recent scientific-based evidence and believes women of average risk should begin breast cancer screening at age 40. We know that women are being diagnosed with breast cancer at younger ages, often with aggressive forms of the disease, and beginning screening at age 40 can help save more lives from this disease.
“Mammograms are the best tool we have for detecting breast cancer. While the USPSTF only recommends screening take place every other year, Susan G. Komen believes screening should be done every year to catch cancer as early as possible when outcomes are generally better and treatment costs less.
“Importantly, these new draft recommendations are only for women of average risk. Black women are 40% more likely to die of breast cancer and breast cancer is the most common form of cancer among Latina women, so it is important that women discuss screening plans with their doctor and develop a plan that is based on their personal risk. “Screening rates declined during the COVID-19 pandemic and many breast cancers went undetected. Additionally, many barriers still prevent women from accessing screening and necessary diagnostic imaging every year. Susan G. Komen urges all women to prioritize breast cancer screening so we can continue to make progress in the fight against breast cancer.”
American Cancer Society applauds USPSTF recommendation The American Cancer Society’s (ACS) chief scientific officer, Dr William Dahut, commented: “We applaud the return in USPSTF recommendations to begin screening in their 40s. However, further consideration may be required as to the frequency of screening for women under age 55. Current evidence indicates that biennial screening in this population
is associated with a diagnosis of more advanced disease.”
ACS breast cancer guidelines https://www.cancer.org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/breast-cancer-screening-guidelines.html , which are evidence-based and independent from USPSTF recommendations, call for women to have an opportunity to decide about beginning screening at age 40, but by age 45 to begin screening and undergo annual screening.
Variances also exist in guidance for women over the age of 74. Whereas the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older, ACS guidelines recommend that women should continue screening as long as they are in good health and are expected to live at least 10 more years.
“At the age of 75, the median life expectancy is greater than ten years, and many women 75 and older will be active and in good health for many more years. Because approximately one in four breast cancer deaths each year is attributable to a diagnosis after age 75, there is no reason to believe that the benefits that are evident in older women before age 74 would not carry forward with increasing age, not only preventing breast cancer deaths but avoiding suffering in the last years of life from aggressive therapy for advanced breast cancer. The ACS believes health and life expectancy, not simply age, must be considered in screening decisions, as spelled out in our current guideline,” said Dr Dahut.
