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Alarmed by an increase in breast cancer diagnoses among younger women and persistently high death rates among Black women in particular, health experts Tuesday said women should start getting mammograms at the age of 40, rather than 50.
According to new draft recommendations from the U.S. Preventive Services Task Force, the health panel found that starting breast cancer screening 10 years earlier could save thousands of lives per year.
The recommendations state that women who are between ages 40 and 74 should have screening mammograms every two years. The guidance would apply to cisgender women and everyone else assigned female at birth.
The group issues influential guidelines on preventive health, and its recommendations usually are widely adopted in the United States. But the new advice, issued as a draft, represents something of a reversal.
In 2009, the task force raised the age for starting routine mammograms to 50, from 40. At the time, researchers were concerned that earlier screening would do more harm than good, leading to unnecessary treatment in younger women, including biopsies that turn out to be negative.
But there have been troubling trends in breast cancer in recent years.
Recent evidence shows more women in their 40s are getting breast cancer, with the number of newly diagnosed women increasing about 2 percent each year, said John Wong, an internist and professor of medicine at Tufts University School of Medicine, who is on the task force.
They include a failure to narrow the survival gap for younger Black women, who die of breast cancer at twice the rate of white women of the same age.
The panel now estimates that by starting screening earlier, doctors can detect breast cancers earlier, saving more lives.
“It is now clear that screening every other year starting at age 40 has the potential to save about 20 percent more lives among all women, and there is even greater potential benefit for Black women, who are much more likely to die from breast cancer,” Wong said.
The new recommendation covers more than 20 million women in the United States between ages 40 and 49.
In 2019, about 60% of women in this age group said they had gotten a mammogram in the past two years, compared with 76% of women ages 50 to 64 and 78% of women ages 65 to 74.
The panel has said there is insufficient evidence to make recommendations one way or the other for women who were 75 and older.
Dr. Carol Mangione, immediate past chair of the task force, said the task force had for the first time commissioned studies of breast cancer specifically among Black women, as well as for all women, and needed more research into the factors driving the racial disparity. The task force also is calling for a clinical trial to compare the effectiveness of annual and biennial screening among Black women.
Black women are at higher risk than white women of developing breast cancer before age 40 and are more likely to develop a more aggressive form called triple-negative breast cancer, according to data from the American Cancer Society.
Overall, mortality from breast cancer has declined in recent years. Still, breast cancer is the most common cancer among women in the United States, aside from skin cancers, and the second-leading cause of cancer-related death in women.
More than 43,000 women die of breast cancer each year in the United States, the data show.
2% RISE PER YEAR
Breast cancer diagnoses among women in their 40s had been increasing at less than 1% between 2000 and 2015. But the rate rose 2% a year on average between 2015 and 2019, the task force noted.
The reasons are not entirely clear.
Postponement of childbearing, or not having children at all, may be fueling the rise, said Rebecca Siegel, senior scientific director of surveillance research at the American Cancer Society. Having children before age 35 reduces the risk of breast cancer, as does breast feeding.
Still, she noted, there is much year-to-year variation in the diagnosis rates. Other researchers suggest the increase among younger women may simply reflect more screening, said Dr. Steven Woloshin, professor of medicine at Dartmouth College.
Frequent screening can itself cause harm, leading to unnecessary biopsies that cause anxiety and treatment for slow-growing cancers that would never have been life-threatening, researchers have found.
Yet there was a firestorm of criticism in 2009, from both patients and advocacy groups, when the task force advised that women start getting regular mammograms no later than 50. Critics of that guidance feared that malignancies would be missed among younger women and suggested that a desire to cut health care costs drove the recommendation.
At the time, the panel also called for longer intervals between mammograms: one every two years, rather than annual scans. That recommendation still stands.
The American Cancer Society differs on this key point. Women ages 40 to 44 should be able to choose screening, the society says, but beginning at 45, women should get mammograms every year until age 55, when the risk of breast cancer begins to drop.
Karen Knudsen, chief executive officer of the cancer society, said she welcomed the task force’s advice to begin routine screening at a younger age because it will alleviate confusion resulting from contradictory recommendations from medical groups.
Still, she said, “We are steadfast on annual screening. Cancers in premenopausal women grow faster, and it’s important they don’t develop during the two-year period and go undetected.”
The task force’s new recommendation applies to all people assigned female at birth who are asymptomatic and at average risk for breast cancer, including those with dense breast tissue and a family history of breast cancer.
But the advice does not apply to anyone who already has had breast cancer, carries genetic mutations that increase risk, has had breast lesions identified in previous biopsies or has had high-dose radiation to the chest, which raises the risk of cancer.
These women should consult with their doctors about how frequently to be screened.
The task force emphasized that it was important for Black women to start mammograms at age 40, as they are more likely to get aggressive tumors at a young age and 40% more likely to die from breast cancer than white women are.
GO FARTHER, CRITICS URGE
Many breast cancer experts applauded the task force for lowering the recommended age that women should start screening mammography. Still, some professional organizations and physicians who focus on breast health say the recommendations don’t go far enough, and they are urging the task force to advise annual mammograms to screen for cancer.
Critics say that for women, an annual appointment for a mammogram is easier to remember than an every-other-year appointment. More importantly, they note that skipping a year between screenings would give undetected cancers more time to grow.
“A two-year interval can allow a more aggressive breast cancer to grow significantly and reduce the chance of the patient being cured or increase the chance that she needs additional treatment,” said Maxine Jochelson, chief of the breast imaging service at Memorial Sloan Kettering Cancer Center.
But limiting screening to every other year can also reduce risk for false positives.
About 12% of screening mammograms result in callbacks, in which a woman is asked to return for additional testing because of an abnormality on the scan. Only 4.45 of those calls, or 0.5%, conclude with a cancer diagnosis, according to a study of nearly 3 million screening exams.
Jochelson said that while callbacks are stressful for women, that shouldn’t be a reason to recommend against annual screening.
The American College of Radiology and Society of Breast Imaging state that women at average risk should start annual mammograms at 40, but by 25, all women should talk to their doctors about their individual risk factors to determine whether earlier screening may be needed for them.
“The risk of getting called back is something they have been talking about for a long time,” she said. “Yes, women are anxious when they are called back for screening mammograms. And I certainly appreciate the anxiety. But then most of them have a normal exam, and life goes on.”
Most doctors and insurance companies follow the recommendations of the task force, which is an independent board of doctors and other experts appointed by the Department of Health and Human Services to evaluate care aimed at prevention or early detection.
But a number of other organizations have made different recommendations about mammography screening, and the wide variation in advice has been confusing for women and their doctors.
William Dahut, chief scientific officer of the American Cancer Society, said these opposing views can be a problem.
“I think it’s hard enough for physicians to keep track, much less to have patients have a sense of what they should be doing,” he said. “Simplifying guidelines — making them as cohesive across different organizations — is a goal we all should work for.”
Professional organizations, physicians and individuals can visit the task force’s website to weigh in on the proposed draft until June 5. Once the recommendations have been finalized, they will be published in JAMA, the American Medical Association’s journal.
Information for this article was contributed by Roni Caryn Rabin of The New York Times and by Lindsey Bever of The Washington Post.
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