Breast cancer screening should start at age 40 – 10 years earlier than previous advice, group says

Women should be screened for breast cancer every other year starting at age 40 instead of 50, according to draft guidelines released Tuesday by the United States Preventive Services Task Force, the independent national body of experts that sets standards for tests and screenings.

The previous recommendations, last updated in 2016, said women younger than 50 who are concerned could discuss screening with their doctors. Now, the task force says screening at 40 could save 19% more lives.

Experts say the guidelines are a leap in the right direction but should go further to advise women to be screened annually. Several other leading groups have long recommended yearly mammograms starting at age 40.

“Cancers do grow between mammograms," said Dr. Maxine Jochelson, a radiologist at Memorial Sloan Kettering Cancer Center. She agreed that beginning screenings at 40 is the "right answer for average risk women."

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.

Breast cancer clinicians have long called for lowering the recommended age for a woman’s first mammogram, especially for Black women, who are more likely to be diagnosed at earlier ages or with aggressive subtypes and are 40% more likely than white women to die of breast cancer.

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Nearly 1 in 5 Black women with breast cancer are diagnosed with triple-negative breast cancer, a type that grows and spreads more quickly, is difficult to treat and lacks three receptors commonly found in breast cancers that doctors target for treatment.

The task force is “also calling for more research on how best to address health disparities across screening and treatment," task force member and internist Dr. John Wong, chief of the division of clinical decision making at Tufts Medical Center, told USA TODAY.

Breast cancer is also the second-leading cause of cancer-related death for white, Asian, Pacific Islander, American Indian and Alaska Native women, though Asian and Pacific Islander women have the lowest breast cancer death rate of all groups.

The guidelines will become official after the task force reviews feedback during the public comment period that ends June 5. The recommendations apply to women, including those assigned female at birth, transgender men and nonbinary people.

Why experts say the new guidelines still fall short

Most organizations recommend annual mammograms starting at age 40, including the American College of Radiology, the American Society of Breast Surgeons, and the American College of Obstetricians and Gynecologists.

But the task force is the official body that many primary care doctors follow for preventive testing. Its recommendations are based on review of existing evidence and is supported by the federal Agency for Healthcare Research and Quality.

Private insurance plans generally base coverage off the task force's recommendations, though the Centers for Disease Control and Prevention says most insurance plans are required to cover mammograms starting at age 40.

In announcing the new draft guidelines, the task force said it chose to keep the recommendation at every other year because of an increased risk of false positives diagnosis. It said callbacks can cause patients to worry or lead to unnecessary biopsies.

But experts say the harms of missed cancers outweigh that worry, and advanced imaging and biopsies can address false positives.

“The guidelines are worrisome,” said Dr. Michele Blackwood, chief of breast surgery at Rutgers Cancer Institute of New Jersey and member of the American Society of Breast Surgeons. “Most of us in this realm still vociferously support yearly mammograms for women over age 40.”

Women diagnosed under age 50 are more likely to be diagnosed with aggressive cancers, and many women skipped mammograms during the COVID-19 pandemic and are seeing later-stage diagnoses, Blackwood said. It's time, she said, "to focus on harms of not screening."

The American College of Radiology also recommends high-risk groups such as Black women and Ashkenazi Jewish women get risk assessments by age 25 to determine whether a mammogram before age 40 is needed.

Unified guidance is needed, said Dr. Vivian Bea, section chief of breast surgical oncology at NewYork-Presbyterian Brooklyn Methodist Hospital and a breast surgeon at Weill Cornell Medicine.

"It's confusing for physicians and providers who are then counseling patients," she said. "It's also confusing for patients."

Dr. Ryland Gore, a breast surgical oncologist in Atlanta, said the Preventative Services Task Force could benefit from having an oncologist − a cancer doctor − on the task force.

“It's estimated that about 300,000 new cases will be diagnosed this year, but breast cancer numbers are not going down," Gore said. "Imagine how many you potentially miss by saying, ‘Oh, you can just do this every other year.’ That is not good enough."

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What about breast density?

Cancer can go under the radar in people with dense breasts, which means they have more fibrous tissue than fatty tissue. Nearly half of all women have dense breasts, which increases the risk for breast cancer.

Experts say mammograms may miss tumors in people with dense breasts and that they may be better detected by ultrasound or MRI. But in its draft guidelines, the task force concluded “that the evidence is insufficient to determine the balance of benefits and harms of supplemental screening for breast cancer with breast ultrasound or MRI, regardless of breast density.”

"Dense breasts make it harder to find the cancer on the mammogram," Jochelson said. "And so, what happens is you miss it on the mammogram, and then you might find it on the next mammogram. But it's going to have a year to grow.”

MRI was the best supplemental imaging in women with dense breasts who had average to intermediate risk for breast cancer and whose mammographies were negative for cancer, according to a meta-analysis of 22 studies published in the journal Radiology in January. Of more than 132,000 patients with dense breasts, 541 cancers missed by mammography were detected with alternative imaging.

As of 2019, at least 38 states had laws mandating clinicians inform patients that they have dense breasts. In March the U.S. Food and Drug Administration, which is responsible for regulating mammography standards, updated regulations to require mammography facilities to inform patients if they have dense breasts.

“We can save more lives by doing yearly and doing supplemental imaging," Jochelson said. "I don't doubt it for a second.”

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Risk factors for breast cancer

According to the CDC, risk factors include:

• Dense breast tissue. This increases the risk of breast cancer and can make it harder to see a tumor by mammogram. Ask your mammographer to let you know if you have dense breast tissue, and if you do, discuss with your clinician whether they recommend additional imaging like ultrasound or MRI.

• Family history. Risk is higher for people with a first-degree relative – mother, sister or daughter – or multiple relatives on either the maternal or paternal side who have had breast or ovarian cancers.

• Age. Breast cancer risk increases as a person ages.

• Genetic mutations. People with inherited changes in genes, such as BRCA1 and BRCA2, are at higher risk for breast and ovarian cancers.

• Previous history. Prior diagnoses of breast cancer increases the risk for a second diagnosis.

The CDC says there are also risk factors that can be reduced. These include not exercising, being overweight or obese, taking certain forms of hormone replacement therapy during menopause and certain oral contraceptives, and drinking alcohol.

Reach Nada Hassanein at nhassanein@usatoday.com or on Twitter @nhassanein.

This article originally appeared on USA TODAY: Breast cancer mammograms should begin at age 40, USPSTF guidelines say