USPSTF: Women should be screened for breast cancer every other year starting at age 40

Key takeaways:

• USPSTF recommends women aged 40 to 74 years undergo breast cancer screening biennially.
• Evidence is insufficient to assess the benefits and harms of breast cancer screening for women aged at least 75 years.

Women should be screened for breast cancer every other year starting at age 40 years, according to a new recommendation statement from the U.S. Preventive Services Task Force.

The grade B recommendation is an update to the 2016 USPSTF recommendation that women aged 50 to 74 years should be screened for breast cancer every other year and that women aged 40 to 49 years should make individual decisions on screening based on individual risk, personal preferences and values.

“In 2023, an estimated 43,170 women died of breast cancer. Non-Hispanic white women have the highest incidence of breast cancer, and non-Hispanic Black women have the second highest incidence rate,” Wanda K. Nicholson, MD, MPH, MBA, chair of the USPSTF and senior associate dean of diversity, equity and inclusion at the George Washington University Milken Institute School of Public Health, and colleagues wrote. “Incidence gradually increased among women aged 40 to 49 years from 2000 to 2015 but increased more noticeably from 2015 to 2019, with a 2% average annual increase.”

The recommendation was based on a systematic review comparing different breast cancer screening strategies and a modeling study estimating outcomes of different mammography screening strategies.

Systematic review

In the systematic review, researchers identified seven randomized clinical trials and 13 nonrandomized studies from MEDLINE and the Cochrane Library published from 2014 to August 2022 comparing breast cancer screening strategies. Primary outcomes were mortality, morbidity, progression to advanced cancer, interval cancers and screening harms.

Researchers estimated no difference in mortality for breast cancer screening from age 75 to 84 years compared with no screening in a nonrandomized trial emulation study (adjusted HR = 1; 95% CI, 0.83-1.19). In three trials comparing digital breast tomosynthesis (DBT) mammography with digital mammography alone, researchers detected more invasive cancers at first screening with DBT (pooled RR = 1.41; 95% CI, 1.2-1.64). However, researchers observed no statistically significant differences at subsequent screening. Advanced cancer risk at the subsequent screening was also not statistically significant for DBT vs. digital mammography.

In a randomized controlled trial with 40,373 women aged 50 to 75 years with extremely dense breasts and negative mammography findings, women reported reduced interval cancer risk with supplemental screening with MRI compared with digital mammography (RR = 0.47; 95% CI, 0.29-0.77).

In addition, one randomized controlled trial reported 48 per 1,000 additional false-positive biopsies among women who underwent ultrasound and digital mammography and no statistically significant difference in invasive false-negative and incident cancer. A nonrandomized study reported doubled false-positive biopsy rates among women who underwent mammography and ultrasonography on the same day (adjusted RR = 2.23; 95% CI, 1.3-2.58), but there was no statistical difference in the risk for false-negative and incident cancer.

Modeling study

In the modeling study, researchers used six Cancer Intervention and Surveillance Modeling Network (CISNET) models to evaluate the benefits and harms of 36 mammography screening strategies with digital mammography or DBT annually, biennially or a combination of intervals. Age at initiation ranged from 40 to 50 years and age at conclusion ranged from 74 to 79 years.

Per 1,000 women screened, DBT biennial screening from age 40 to 74 years prevented an estimated 8.2 deaths, 7.5 deaths from age 45 to 74 years and 6.7 deaths from age 50 to 74 years compared with no screening. Digital mammography screening benefits were similar to those of DBT from age 40 to 74 years, but digital mammography resulted in more false-positive recalls (1,540 vs. 1,376).

Annual screening mammography from age 40 to 74 years with DBT or digital mammography increased median reductions in breast cancer mortality to 37% and 35.2%, respectively. Annual screening with digital mammography or DBT from age 40 to 74 years led to more false-positive recalls (2,423 and 2,096 vs. 1,540 and 1,376) and overdiagnosed cases (21 and 19 vs. 12 and 14) vs. biennial screening with digital mammography or DBT.

In addition, for Black women, biennial DBT for women aged 40 to 49 years may prevent a median of 1.8 additional breast cancer deaths per 1,000 women screened.

Current recommendation

The recommendations apply to cisgender women and those assigned female at birth aged 40 years or older who are at average risk for breast cancer and those with factors associated with increased breast cancer risk, such as family breast cancer history or having dense breasts. The recommendations do not apply to those with genetic markers or syndromes associated with a high breast cancer risk, a history of high-dose radiation therapy to the chest at a young age, previous breast cancer or a high-risk breast lesion on previous biopsies.

Current evidence is insufficient to analyze the benefits and harms of mammography for women aged 75 years and older, according to the USPSTF.

“In clinical practice, the majority of patients are undergoing annual screening with mammogram, instead of once every 2-year screening interval. Practically, in the urban setting, most patients are already and will continue to have screening with mammogram with tomosynthesis,” Nancy Chan, MD, a medical oncologist at the NYU Langone Perlmutter Cancer Center, said in a statement regarding the new recommendation. “Each patient must consider the best screening method for their individual cancer risk, such as breast density, family history, etc.”

In an accompanying editorial, Joann G. Elmore, MD, MPH, professor in the department of medicine at the National Clinician Scholar Program at the David Geffen School of Medicine at UCLA, and Christoph I. Lee, MD, MS, MBA, professor in the department of radiology and the department of health systems and population health at the University of Washington School of Medicine and Fred Hutchinson Cancer Center, noted that the updated USPSTF recommendations highlight a rapidly evolving intersection of technology and equity within a health care ecosystem where disparities remain a “persistent problem.”

“It is important that physicians continue to practice the art of medicine to ensure that women make informed decisions aligned with their preferences,” Elmore and Lee wrote. “Moving ahead, population-level data collection throughout the entire breast care continuum is imperative to pinpoint interventions at individual, neighborhood and health care facility levels that can help address existing disparities gaps across the entire screening and diagnostic episode of care.”

These finalized UPSTSF breast cancer screening recommendations align with the draft recommendations announced in May 2023.

References:

• Elmore JG, et al. JAMA. 2024;doi:10.1001/jama.2024.6052.
• Henderson JT, et al. JAMA. 2024;doi:10.1001/jama.2023.25844.
• Trentham-Dietz A, et al. JAMA. 2024;doi:10.1001/jama.2023.24766.