Younger women advised to get mammograms at age 40 but questions remain about how often

CLEVELAND, Ohio — As an OB/GYN, Dr. Lauren Bouchard frequently asks her patients about their family history of breast cancer. She advises those with close relatives who developed breast cancer to get mammograms annually starting at age 40.

That’s close to the new draft guidelines recently issued by the U.S. Preventive Services Task Force, an independent panel of experts that makes recommendations for preventive screenings for disorders such as depression and hepatitis C.

The updated guidelines recommend that women at average risk for breast cancer begin mammograms at age 40 — a decade earlier than the previous guidelines — and continue every other year until age 74.

The task force’s announcement of new guidelines brought up questions in the breast cancer community. Should women at average risk for the disease start mammograms at age 40, or age 50? Should they get mammograms every year, or every other year?

And should Black women — who die at a greater rate from breast cancer than white women — start mammograms earlier or get them more often?

Answers vary among different medical organizations, physicians and hospital systems, which breeds confusion among women worried about their chances of getting breast cancer.

“It’s a very complex issue. There’s so many different opinions and knowing what is the right thing to do isn’t always so easy,” said Dr. Laura Dean, breast radiologist at the Cleveland Clinic. “We just really try to go with the best evidence.”

Breast cancer is the second leading cause of cancer death after lung cancer in women in the United States overall, but it’s the leading cause of cancer death in Black and Hispanic women, according to the American Cancer Society.

The good news Is that mammograms — breast X-rays that detect signs of cancer — are the best way to detect breast cancer early while it is easier to treat.

But frequent mammograms also can lead to false positive results, unnecessary biopsies and higher costs, physicians say.

Bouchard sees mostly African-American patients at the Euclid-based women’s health clinic Village of Healing. She thinks the updated U.S. Task Force screening guidelines will allow physicians “to identify breast cancer at a younger age, allow us to have more productive treatment discussions for the more aggressive types of breast cancer, and do that sooner rather than waiting to age 50, which was the prior recommendation.”

The U.S. task force routinely updates its recommendation statements every three to five years by looking at the latest data. This year, the organization looked at national population data and a large national data set from the National Cancer Institute. It also used modeling studies to consider various screening strategies, said Dr. Wanda Nicholson, a task force vice chairman and professor of prevention and community health at the Milken Institute School of Public Health at the George Washington University.

“We look for the strongest evidence possible to inform our recommendations,” Nicholson said. The task force’s influential recommendations help determine which procedures health insurance must cover.

However, the new U.S. task force recommendations do not include high-risk women who have a genetic disposition for breast cancer. About 1 in every 500 American women has a mutation in either her BRCA1 or BRCA2 gene mutation, leading to a greater chance of developing breast or ovarian cancer, according to the U.S. Centers for Disease Control and Prevention.

Women at high risk for breast cancer should talk to their healthcare provider about when they should start screening and how often how often they should get mammograms, Nicholson said.

The U.S. task force’s new guidelines stating mammograms should start at 40 is in line with recommendations from the Society for Breast Imaging and the American College of Radiology and other physician groups that agree women should start breast screening at that age.

But the American Cancer Society recommends starting breast cancer screenings later, at age 45.

And the U.S. task force is nearly alone in advocating screenings every other year. The American Cancer Society, along with several physician-led groups, are in favor of annual screenings.

Screening every other year could give cancers an extra year to advance, especially in Black and other minority women, Jewish women, and others who develop and die from breast cancer before reaching 50 more often than white women, the American College of Radiology and the Society of Breast Imaging said in a recent joint statement.

Different organization can vary in their recommendations because of how each one evaluated data, Nicholson said.

“We have very specific and very robust criteria for the studies that we include, so that we can have the best evidence possible for making our recommendations,” Nicholson said.

Screening women at an earlier age means that women will be exposed to more mammograms over a lifetime. That means more opportunities for false positive screenings, unnecessary biopsies of normal tissue, or unneeded treatment of abnormal tissue.

False positive mammograms — in which an image is erroneously flagged for abnormal tissue — happen fairly often, suggested a 2022 study led by UC Davis Health.

Half of all women will experience at least one false positive mammogram if they get annual mammograms over 10 years, the UC Davis Health study suggested.

Unnecessary screenings drive healthcare costs higher, but the U.S. task force does not take the cost of care into account when setting its recommendations, Nicholson said.

Overall, the task force concluded that the benefits outweighed the harms from increased breast cancer screening, Nicholson said.

“The ultimate benefit is saving lives,” Nicholson said. “Our goal links back to our mission (of helping people live) the longest and healthiest life possible.”

Despite the dismal statistics regarding Black women and breast cancer, the task force is not recommending that Black women get mammograms more often, or start them at an earlier age, than the general population, the Clinic’s Dean said.

The reason? There were few randomized trials examining the efficacy of breast cancer screening at earlier ages, Nicholson said.

The task force also determined that the additional benefit for Black women was very small compared to a greater potential harm of false positives, overdiagnosis and overtreatment, Nicholson said.

Mammograms starting at age 40 — in line with the task force’s new guidelines — can help save up to 20% more lives overall, and up to 24% more Black women’s lives, Nicholson said.

“So Black women benefit actually slightly more from this updated recommendation, compared to all women,” Nicholson said.

A large study published this spring in JAMA Network Open suggests that earlier screenings for breast cancer in Black women could help lower racial disparities in breast cancer deaths.

“I think it highlights that we need more research, especially for this community,” Village of Healing’s Bouchard said. “Having more Black women enrolled in research trials will be able to get us better information as to what (kind of) screening and treatments would be best.”

But screenings alone won’t fix the breast cancer disparity in Black women, Nicholson said. She pointed to disparities in the health care system that make it more difficult for Black women to get timely follow-up care after a positive mammogram.

“We want to use this screening recommendation as a platform to say that other downstream steps must occur to achieve this benefit,” Nicholson said.

When a woman gets a mammogram, a specialized machine compresses the breast to make it easier to detect possibly cancerous tissue. Multiple images are taken of each breast, and reviewed by a radiologist.

Digital or 3D mammogram allows for better visibility of possible cancers and decreases the likelihood of false positives, said the Clinic’s Dean.

Breast cancer screenings are available at clinics, hospitals or doctors’ offices. Use this CDC locator link to find a nearby breast screening facility.

The federal government also offers free or low-cost mammograms for those who qualify.

Mammograms also are covered by private health insurance, Medicaid and Medicare.

Most private health insurance plans are required to cover mammograms every one to two years beginning at age 40, with no out-of-pocket costs, according to the CDC.

In Ohio, women on Medicaid between the ages of 35 and 40 can get a free initial breast cancer screening, then one free screening yearly thereafter.

Women with Medicare age 40 and up can get one baseline mammogram between ages 35 and 39, and a screening mammogram every 12 months. There is no cost if the healthcare provider accepts Medicare.

Medicare Part B covers diagnostic mammograms more frequently when deemed medically necessary. Patients pay 20% of the Medicare-approved amount for diagnostic mammograms and the Part B deductible applies.