Lowering the Breast Cancer Screening Age
- Screening for breast cancer is normally done through a mammogram, which looks for lumps in the breast tissue and signs of cancer.
- The U.S. Preventive Services Task Force (USPSTF) recently drafted new recommended guidelines that advise all women to start screening for breast cancer at age 40 – a significant change from 2016, when it said screening should happen between the ages of 50 to 74 years old.
- The USPSTF suggests screening take place every other years, and the guidelines only apply to women with an average risk (including people with a family history of the disease and risk factors like dense breasts).
- While this lower age can help people catch breast cancer earlier – like Black women, who are more likely to die from the disease, it’s important to also consider the potential risks of earlier screening for everyone.
- Risk of mammography screenings are cited as “overdiagnosis, false-positives, anxiety, and radiation injury,” according to a journal published last year in the National Library of Medicine.
Breast cancer is the second most common cancer among women, as well as the second leading cause of cancer death in women, in the United States so it’s no wonder why screening for the disease is so important.Read More
“In general, cancers in younger women can be more aggressive. Therefore, if you are going to screen women between ages 40-50, it should be annually. After age 50, it is reasonable to consider every other year. However, most practicing oncologists would still advocate for annual screening,” she said.
Dr. Amy Comander, medical director and director of Breast Oncology at Mass General Cancer Center Waltham, supported the USPSTF’s lowered age for mammograms.
“This will encourage more women to get screened starting at age 40, so we can detect breast cancers earlier, and save more lives!” she told SurvivorNet.
She highlighted the fact that the incidence of breast cancer for women in their 40s has increased between 2015 and 2019,” and “other organizations such as the American College of Radiology have already recommended that mammographic screening start at age 40, in order to provide the benefit. It is nice to see that the guidelines from the USPSFT are now in alignment with other organizations.”
What to Know About the New Mammogram Recommendations
The new draft guidelines from the USPSTF are a significant change from 2016, when the group recommended breast cancer screening should happen every other year between the ages of 50 to 74 years old.
“While the Task Force has consistently recognized the lifesaving value of mammography, we previously recommended that women in their 40s make an individual decision about when to start screening based on their health history and preferences,” the USPSTF said. “In this new recommendation, the Task Force now recommends that all women get screened starting at age 40.”
The new recommendations apply to women with an average risk of breast cancer, including people with a family history of the disease and risk factors like dense breasts.
The recommendation is not for people with a personal history of breast cancer, who have certain genetic factors putting them at high risk of the disease, who have had high-dose radiation to their chest, or who have had high-risk lesions on previous biopsies.
The task force added that more research needs to be conducted on whether women with dense breasts will need additional screening starting at 40 and what are the pros and cons of screening women older than 75.
Expert Breast Cancer Screening Information
The task force said their new guidelines are based on new data from recent years of younger women developing breast cancer.
“New and more inclusive science about breast cancer in people younger than 50 has enabled us to expand our prior recommendation,” said task force immediate past chair Dr. Carol Mangione, M.D., M.S.P.H.
Additionally, the task force recognizes the “health inequalities” in breast cancer among Black women, who are more likely to die from the disease than white women, according to the American Cancer Society.
“Ensuring Black women start screening at age 40 is an important first step, yet it is not enough to improve the health inequities we face related to breast cancer,” according to USPSTF vice chair Dr. Wanda Nicholson, M.D., M.P.H., M.B.A.
“In our draft recommendation, we underscore the importance of equitable followup after screening and timely and effective treatment of breast cancer and are urgently calling for more research on how to improve the health of Black women,” Dr. Nicholson added.
Breast Cancer survivor, advocate, and SurvivorNet partner Suzette Simon spoke with SurvivorNet following the guidelines news.
“I’m glad the US Preventive Services Task Force (USPSTF) finally woke up from their 14-year nap and proposed new breast cancer screening guidelines. But they still have a long way to go when it comes to saving black boobs,” Simon told SurvivorNet.
She added that women of color “need to know our risk when we’re young and be encouraged to get screened early. Plus, suggesting to get mammograms every other year is alarming. We need to be checking our boobies as much as possible.”
She continued, “Research has shown that yearly mammography starting at age 40 saves more lives, especially for black women who are 40% more likely to die from breast cancer because there is the risk of missed cancers, which could be especially problematic for younger women who may be more likely to develop aggressive cancers.”
Simon also noted that she’s “upset by the lack of guidance for older women and women with dense breasts,” insisting, “Black women are more likely to have dense breasts. Those boobs need some love too! A LOT more love. We need to make sure all women, regardless of age or breast density, are getting the care they need.”
“It’s also important for women to discuss their individual risk factors with their healthcare providers and to make informed decisions about screening based on their personal medical history and recommendations from trusted sources, Simon added, hoping to spread the word about breast cancer risk.
‘An Important Takeaway’ From USPTF’s New Guidelines
According to Dr. Shen, one “important takeaway” from USPSTF’s new guidelines is that “these are only applicable to ‘average risk’ women.”
“Nowadays, as we are increasingly practicing personalized medicine, screening recommendations should be tailored to an individual woman's risk. Studies show there are ‘high risk’ women who may not realize they are ‘high risk.'” Dr. Shen explained.
“There are statistical models which help practitioners determine an individual patient's risk of breast cancer. The most commonly used and accepted one is the IBIS (Tyer-Cuzik) model. So, patients should be encouraged to have these discussions with their physicians and their screening recommendations tailored to their individualized risk.”
The Importance of Breast Cancer Screening
Screening for breast cancer is normally done through a mammogram, which looks for lumps in the breast tissue and signs of cancer.
While there is some disagreement about the exact age a woman should start getting mammograms, doctors generally agree it should happen in their 40s
The American Cancer Society (ACS) suggests women should begin annual mammogram screenings for breast cancer at age 45 if they are at average risk for breast cancer.
The ACS also advises:
- Women aged 40-44 have the option to start screening with a mammogram every year
- Women aged 55 and older can switch to a mammogram every other year
- Women aged 55 and older could also choose to continue yearly mammograms
For screening purposes, a woman is considered to be at average risk if she doesn't have a personal history of breast cancer, a strong family history of breast cancer, a genetic mutation known to increase risk of breast cancer such as a BRCA gene mutation or a medical history including chest radiation therapy before the age of 30.
Experiencing menstruation at an early age (before 12) or having dense breasts can also put you into a high-risk category. If you are at a higher risk for developing breast cancer, you should begin screening earlier.
In a previous interview with SurvivorNet, Dr. Connie Lehman, chief of the Breast Imaging Division at Massachusetts General Hospital, said people who hadn't reached menopause yet should prioritize getting a mammogram every year.
“We know that cancers grow more rapidly in our younger patients, and having that annual mammogram can be lifesaving,” Dr. Lehman explained.
“After menopause, it may be perfectly acceptable to reduce that frequency to every two years. But what I'm most concerned about is the women who haven't been in for a mammogram for two, three or four years, those women that have never had a mammogram. We all agree regular screening mammography saves lives.”
It's also important to be on top of self-breast exams. If you ever feel a lump in your breast, you should be vigilant and speak with your doctor right away. Voicing your concerns as soon as you have them can lead to earlier cancer detection which, in turn, can lead to better outcomes.
When You're Getting a Mammogram, Ask About Dense Breasts
Meanwhile, dense breasts can sometimes make cancer more difficult to detect. Since there's no way to determine if you have dense breasts just by feeling them a mammogram is the only test that can determine if you have it.
To have dense breasts means you have more fibroglandular tissue and less of the fatty breast tissue. This can make it more difficult for a regular mammogram to detect cancer.
The dense tissue has a "masking effect on how well we can perceive cancer and find cancer on mammograms," Dr. Cindy Ly, doctor of radiology at NYU Langone Medical Center, told SurvivorNet.
Because of this, a 3D mammogram is typically performed on women with dense breasts and looks at the tissue in several layers, compared to the single image of a regular mammogram.
Bestselling author and breast cancer survivor Laura Morton learned a really important lesson about advocating for herself when she was getting a mammogram and questioned her radiologist about dense breasts. The radiologist brushed her off.
“I waited until afterward to mention to her how I felt about her response to what is a really important question, you can not feel if you have dense breasts. You have to be told if you have dense breasts,” Laura says.
“So when somebody walks through your door and says, 'Do I have dense breasts?' Answer their question, don't roll your eyes and make them feel small for asking something that we are entitled to know.”
When you go in for your mammogram, consider asking:
- Do I have dense breasts?
- Do I need to consider getting a 3D mammogram?
Earlier Screenings: What’s the Risk?
While the new recommendations for breast cancer screening may help certain women catch breast cancer earlier, it’s important to consider the potential risks associated with earlier screening for everyone.
Most often, risk of mammography screenings are cited as “overdiagnosis, false-positives, anxiety, and radiation injury,” according to a journal published last year in the National Library of Medicine.
“The benefits and risks of mammography screening for women in their 40s are different than for older women due to their longer life expectancy, reduced comorbidities, and greater likelihood of more aggressive breast cancer,” the article states.
One in seven women in the U.S. will be overdiagnosed with breast cancer, according to recent research.
During a presentation of his findings, Marc Rysar, Ph.D., assistant professor in population health sciences at Duke Cancer Institute, defined breast cancer overdiagnosis as the "mammographic detection of breast cancers that would not have caused symptoms or other harm in a woman's remaining lifetime."
Dr. Otis Brawley, a medical oncologist and epidemiologist at Johns Hopkins University, told SurvivorNet during a previous interview that advancements in imaging technology have contributed to more diagnoses.
"One of the things that has happened because of our technology, our improvements in technology over the last just 20 years, is we are now able to diagnose some cancers that never would have been diagnosed in the past," he said.
"We find some prostate cancers, some breast cancers, even some lung cancers that yes, they existed in the past, but we didn't have the ability to image that small or to image those types of cancer. We didn't have the ability to stick a needle in and biopsy such a small lesion."
Dr. Brawley explains that some of the cancer being found now with new technologies was "never destined at a genetic level to grow, spread and kill."
"They look like cancer but they don't need to be cured. This is a hard thing for even doctors to accept. In the 1980s, it was always find it early and cut it out. Now, we're saying there's certain things that we should find early and watch," Dr. Brawley says.
Meanwhile, younger women have been found to have more false positive events and biopsies leading to anxiety, when compared to older women, according to the article.
Overall, early screenings may take a toll on the emotional, physical, psychological, and financial aspects of a person but Dr. Paul Doria-Rose, Ph.D., chief of NCI's Healthcare Assessment Research Branch, tells the National Cancer Institute that “more research is needed to learn how frequently some screening harms happen.”
And for women older than 75 years old questioning whether they should undergo a breast cancer screening, Dr. Nancy Keating, a professor of health care policy and medicine at Harvard Medical School, suggests discussing your concerns with a doctor.
“For women with a 10-year life expectancy, I recommend continued mammography screening,” Dr. Keating tells Harvard Health Publishing.
“For those with less than a 10-year life expectancy, I explain that studies suggest that mammography screening is unlikely to find a cancer that would change their life expectancy, and is more likely to find a cancer that would never become evident otherwise during this time.”
Additionally, Dr. Chen, told SurvivorNet, “In terms of when to stop screening, I generally advise women that as long as they have life expectancy 5-10 years or greater, and are in good enough health to accept treatment, it is reasonable to continue screening.”
“While studies may not show decreased mortality for screening older women, early detection of an asymptomatic tumor in a healthy woman can result in more treatment choices which can lead to decreased treatment associated morbidity and improved quality of life,” Chen added.
Understanding Your Breast Cancer Risk
The risk of developing breast cancer varies greatly from person to person, so it's important to discuss your specific risk level with your doctor. That being said, there are some important risk factors to keep in mind.
In a previous interview with SurvivorNet, Dr. Elizabeth Comen, a medical oncologist at Memorial Sloan Kettering Cancer Center, laid out several risk factors for breast cancer including:
- Being a woman: Women are at a higher risk for breast cancer, though men can get the disease too.
- Age: "Breast cancer becomes increasingly more common as women age," Dr. Comen said.
- Family history: “Some people think that breast cancer is only inherited through genes on the mom's side,” Dr. Comen said. “But it can also be related to genetic mutations that could be found on the father's side.”
- Having had a prior biopsy on an abnormal area: “There are different markers, that if a woman has had a biopsy, it's important that she talk to her doctor about whether those markers are lending themselves to an increased risk of breast cancer,” Dr. Comen said. If you've had a biopsy that indicated atypical hyperplasia, for example, you are at an increased risk of breast cancer. Atypical hyperplasia isn't cancer, but it is a precancerous condition that describes an accumulation of abnormal cells in the milk ducts and lobules of the breast.
- Radiation exposure: Cancer survivors who've had radiation to their chest are at an increased risk of breast cancer.
- Lifetime estrogen exposure: “About 2/3 of breast cancer are driven by the hormone estrogen,” Dr. Comen said. “So, that means if a woman has had her period at an early age and started to go through puberty at an early age, at seven, eight, nine, and potentially a later age of menopause, means that her lifetime of having had menstrual periods and being exposed to higher levels of estrogen is higher, and therefore her risk of breast cancer is slightly higher.”
- Not having a child before age 30 or never having children
- Drinking alcohol
- Lack of exercise: “While there's more research to be done in this area, it looks like if a woman is not exercising, she may also increase her risk for breast cancer,” Dr. Comen said.
Contributing: SurvivorNet Staff