Women are now advised to undergo a mammogram every other year from the age of 40 to 74, as per fresh guidelines issued by the US Preventive Services Task Force.
The USPSTF, a volunteer panel of autonomous medical experts whose suggestions influence doctors’ decisions and impact insurance plans, previously proposed biennial mammograms commencing at 50, with screening in one's 40s being a "personal choice."
These fresh directives, revealed Tuesday in the medical publication JAMA, supplant the task force’s 2016 suggestions. Some factions, like the American Cancer Society, have already advocated for commencing mammograms in one's 40s.
The revised USPSTF guidelines encompass all individuals designated female at birth, including cisgender women, transgender men, and nonbinary individuals with an average risk of breast cancer, as well as those with a family history of the disease or dense breast tissue.
These updated recommendations do not extend to individuals with a personal breast cancer history, genetic predisposition like the BRCA1 or BRCA2 genes, or a background of high-dose chest radiation therapy or high-risk breast lesions. Such patients should either adhere to their physician's plan or consult with their doctor for personalized advice.
"We present this fresh recommendation update as the most recent scientific evidence demonstrates that commencing mammograms at age 40 and undergoing them biennially until age 74 can further diminish breast cancer mortality," stated USPSTF Chair Dr. Wanda Nicholson, a distinguished faculty member at George Washington University’s Milken Institute School of Public Health.
The advantage of breast cancer screening lies in its ability to detect cases early, thereby reducing the likelihood of succumbing to the disease.
Breast cancer ranks as the second most prevalent cancer among women in the US, trailing only skin cancer, and stands as the second-leading cause of cancer-related mortality, following lung cancer.
Nicholson expressed, "We can potentially save even more lives — up to almost 20% more — with this updated approach."
Why not screen every year?
About 1 in 8 women will develop invasive breast cancer during their lifetime, according to the American Cancer Society, and mammography — capturing an X-ray of the breast — remains the premier method for screening and detecting the disease.
The USPSTF has faced criticism for advocating biennial screenings instead of annual ones.
“Following USPSTF terminology, annual screening is equally 'efficient' as biennial screening but yields greater reductions in late-stage disease and breast cancer-related deaths, along with increased gains in years of life saved,” remarked Dr. Wendie Berg, from the University of Pittsburgh School of Medicine, in an editorial featured Tuesday in JAMA Oncology. She noted it's surprising the USPSTF suggests biennial over annual screening.
“The updated USPSTF recommendations mark a significant step forward, yet they fall short. Annual mammography is as effective as biennial mammography but offers greater overall gains in years of life saved,” Berg emphasized. “Annual screening holds particular importance for premenopausal women, notably those in racial and ethnic minority groups.”
Alongside the recommendation for biennial screening, concerns arise regarding the USPSTF's blanket recommendations for both average-risk individuals and those with a family history of breast cancer or dense breast tissue, highlighted Molly Guthrie, vice president of policy and advocacy at Susan G. Komen.
Roughly half of women over 40 in the US have dense breast tissue, according to the US Food and Drug Administration, which last year updated mammography regulations to mandate that all US screening facilities disclose breast density to patients alongside their mammography results.
“We were quite taken aback by how they segmented their target audiences, which doesn't align with current practices in identifying those at high risk of breast cancer,” Guthrie stated. “I'm concerned this may further confuse people about what actions they should take.”
Experts suggest individuals with a direct family history of breast cancer or dense breast tissue might require different screening recommendations, given both factors are linked to increased breast cancer risk. Guthrie advised women to discuss their personal and family medical history with their doctors to determine the most suitable screening approach.
“The task force guidelines have both positive and negative implications since they directly influence health plans' obligation to cover screenings at no cost,” Guthrie noted. By not endorsing annual screening, “we're concerned the updated recommendation could reduce screening access and utilization, potentially leading to more late-stage diagnoses, which are harder to treat and more costly for the healthcare system overall.”
USPSTF members found no evidence supporting annual screening in their review of published research and data, Nicholson affirmed.
“At present, there are no randomized trials comparing annual to biennial screening. However, our systematic evidence review, a fundamental aspect of all our recommendations, revealed no increase in later-stage breast cancer diagnoses with biennial screening compared to annual screening,” Nicholson explained. “Our modeling studies indicated a more favorable balance of benefits and harms with biennial screening. With annual screening, there was a 50% higher rate of false positive results.”
False positives in breast cancer screening occur when a mammogram indicates abnormality despite the absence of cancer, leading to additional biopsies, repeated tests, and emotional stress for patients.
“Undergoing screening every other year maximizes its benefits while minimizing associated harms. These harms may include false alarms suggesting cancer when there isn't any, or missing cancer when it's present, as well as receiving unnecessary treatment,” according to a patient fact sheet from the USPSTF.
The USPSTF's shift from advocating individualized screening decisions for women in their 40s to recommending screening initiation at age 40 appears to align more closely with recommendations from other organizations.
The American Cancer Society suggests women aged 40 to 44 consider yearly mammograms, with those aged 45 to 55 advised to undergo annual screenings, and women over 55 transitioning to biennial mammograms.
“The USPSTF's decision is a significant milestone in women's health and the fight against breast cancer, recognizing the benefits of mammography screening for women in their 40s and reinforcing the message to physicians and women that screening should start before age 50,” Dr. Karen Knudsen, CEO of the American Cancer Society, remarked in a statement.
“Mammography screening is fundamental to detecting this potentially lethal disease early, when treatment is more effective,” Knudsen added. “However, we're disappointed the updated recommendations don't include women over 74. Many women in this age group are in good health and expected to live for many more years, during which their risk of breast cancer remains significant.”
The American College of Obstetricians and Gynecologists advises average-risk women to undergo screening every one to two years starting at age 40, beginning no later than age 50. These recommendations advocate screening until at least age 75.
Benefits and harms of screening
To support the updated screening guidelines, task force members examined data from seven randomized clinical trials and 13 non-randomized studies, along with a fresh modeling study.
“We evaluated the balance of benefits and harms concerning interval screening and screening initiation age,” Nicholson explained.
The USPSTF determined that biennial breast cancer screening between ages 40 and 74 reduced the risk of breast cancer mortality. However, evidence was insufficient to assess the benefits and harms of screening for women 75 and older. The task force also lacked evidence to evaluate supplemental screening for women with dense breasts.
The revised recommendation endorses both traditional digital mammography and digital breast tomosynthesis, or "3D mammography," as effective screening methods.
Nicholson noted that the USPSTF regularly reviews its recommendations every five years, considering new evidence for updates.
For these new recommendations, the USPSTF observed a clear increase in invasive breast cancer incidence among women aged 40 to 49.
“We observed a rising trend in invasive breast cancer diagnoses among women in their 40s,” she said. “For the first time, we had data on Black women, revealing they face a nearly 40% higher risk of dying from breast cancer compared to White women. This updated observational data informed our collaborative modeling studies.”
The updated guidelines acknowledge significant disparities in breast cancer, particularly among Black women who are more likely to be diagnosed at later stages and have higher mortality rates despite lower overall diagnosis rates.
The task force emphasized the need for thorough research to understand and address these disparities.
“We need research to uncover the underlying causes of why Black women experience more aggressive cancers. It could be a mix of environmental factors and social determinants of health,” Nicholson explained. “Furthermore, we need insights into addressing these disparities within our healthcare system and exploring optimal screening strategies tailored to Black women.”
The revised recommendations illuminate two critical issues: tackling health disparities in breast cancer and ensuring all women can access advancements in screening technologies.
“Encouraging earlier screening starting at age 40 is just one aspect of the broader breast care continuum. It assumes women have access to up-to-date screening facilities, receive timely diagnostic assessments, and access high-quality treatment—realities that may not always hold, especially for underserved and under-resourced communities,” wrote Dr. Joann Elmore of the David Geffen School of Medicine at UCLA and Dr. Christoph Lee of the University of Washington School of Medicine in a joint editorial published in JAMA.
“In summary, the updated USPSTF recommendations underscore the evolving intersection of technology and equity within a complex healthcare landscape where disparities persist. Physicians must continue practicing the art of medicine to ensure women make informed decisions aligned with their preferences.”
