Opinion | It’s Time for a Risk-Adapted Approach to Breast Cancer Screening

Breast cancer is the second leading cause of cancer death in women in the U.S., and there is a substantial disparity in breast cancer mortality by race, particularly for early-onset breast cancer in Black women. In a recent study I co-authored and published in JAMA Network Open, we showed that if breast cancer screening is recommended to begin at age 50 years for the general female population (as the U.S. Preventive Services Task Force [USPSTF] currently recommends), Black women should begin breast cancer screening 8 years earlier, at age 42 years, whereas white women could begin screening at age 51 years, American Indian or Alaska Native and Hispanic women at age 57 years, and Asian or Pacific Islander women at age 61 years.

A risk-adapted approach to breast cancer screening in the U.S. may help reduce racial disparities in breast cancer mortality and may promote optimal resource allocation.

Who Is at High Risk?

A one-size-fits-all policy of starting screening all women from a certain age may not be fair, equitable, or optimal. The current policy fails to address the significant disparity in breast cancer mortality between Black and white women, which has remained stable since 2011 despite widening over 3 decades prior. The mortality rate in Black women is 40% higher than in white women. This disparity is exacerbated among Black women under age 50, who have a mortality rate twice that of white women. To address this disparity, healthcare providers must identify women at high risk and target screening efforts to those who are most likely to benefit from early detection.

Some guidelines recommend starting screening for all women at age 40 or age 45. However, I believe lowering the starting age of screening for “all” women from 50 to younger ages would waste cancer prevention resources and bring harm to women at low risk. Instead, it would be more equitable to screen women at high risk earlier and those at low risk later.

Asian or Pacific Islander women and, to some extent, Hispanic (and American Indian or Alaska Native) women, either in their country of origin or as immigrants, have a lower risk of breast cancer and breast cancer mortality than other women. Screening these women at low risk as early and as often as other women may do more harm than good. Research on this issue is urgently needed. One of the harms of overdiagnosis of breast cancer through unnecessary early screening is overtreatment — receiving unnecessary treatments such as surgery, chemotherapy, radiation therapy, or hormone therapy with potentially serious side effects, including pain, fatigue, and emotional distress. Earlier or more frequent screening can result in false-positive findings, which can cause anxiety, lead to unnecessary biopsies, and increase healthcare costs. Overdiagnosis and overtreatment of breast cancer can lead to increased healthcare costs for individuals and society, as well as potential lost income due to time away from work for treatment. They can also cause emotional harm, including depression, anxiety, and reduced quality of life.

The Benefits of a Targeted Approach

By targeting screening efforts to women at high risk, healthcare providers can optimize resource allocation and ensure that screening efforts are focused where they are most needed. Implementing a risk-adapted approach to breast cancer screening may also improve breast cancer screening participation rates in minority populations. Since not all minority groups are at high risk for breast cancer mortality, our recent race-adapted screening study also helps identify the appropriate, high-risk cohort of women for a targeted outreach and public education to increase awareness and encourage early screening.

Another benefit may be the reduction in barriers to care, as the assumption that Black women in the U.S. face more barriers “after” screening may not be true for the breast cancers that occur in women under 50 years. A sophisticated simulation modeling study estimated that biennial mammograms for Black women starting at age 40 years would be associated with a 57% reduction in the mortality gap in breast cancer in this population compared with white women. Since screening is for “early” detection/diagnosis, the “delay” in diagnosis that leads to the delay in treatment could actually be mitigated. However, it should be noted that screening Black women at younger ages, who have higher breast density and are at increased risk for fast-growing breast cancers, may require screening modalities other than mammography and probably more frequent screening than other women.

The USPSTF recommends age 50 as the start for screening, and adds that women ages 40 to 49 years make an individual decision about screening after discussing the risks and benefits with their primary care practitioners. However, many physicians are not equipped with necessary evidence-based information on how race and ethnicity may influence risk. In other words, guidelines get women to practitioners and practitioners get to the ambiguous guidelines; a vicious cycle that is harmful for Black women at high risk of breast cancer. Studies on race and ethnicity-adapted breast cancer screening provide the precise information that practitioners would need — but many aren’t aware of — for a race and ethnicity-tailored starting age of breast cancer screening.

Evaluating the Impact of Revised Guidelines

Clinical trials are the best way to study the efficacy of a race and ethnicity-tailored screening ages and to investigate whether changes in screening guidelines could alter the disease trajectories and have a population impact. Our recent study provided information that may be needed to design such a trial. On the other hand, it will likely take a decade or more before such trials could prove the efficacy of race-adjusted starting age of screening. After that, additional studies may be needed to prove the real-world effectiveness of new recommendations, because clinical trial enrollee populations may not be representative of the entire female population. Therefore, until trials are designed and their results published, observational studies and high-quality modeling studies can help inform health policy. This will help prevent the current racial disparities in breast cancer mortality from persisting or worsening.

We recommend health policymakers and clinicians consider the evidence-based findings of our recent study and revise guidelines to ensure that high-risk populations receive appropriate screening at the appropriate time. Other necessary measures include targeted public outreach and education efforts to increase awareness and encourage early screening in at-risk populations. The evidence-based risk-adapted starting ages for breast cancer screening provided by our large-scale studies (considering race/ethnicity, detailed family history of breast or ovarian cancer, and reproductive profile) could be the basis for the development of future screening guidelines.

By taking these steps, we can reduce the racial disparities in breast cancer mortality and improve health outcomes for all women.

Mahdi Fallah, MD, PhD, is the leader of the Risk Adapted Prevention Group in the Division of Preventive Oncology at German Cancer Research Center (DKFZ). He is also a visiting professor in the Center for Primary Health Care Research at Lund University in Sweden, and an adjunct professor in the Institute of Primary Health Care (BIHAM) at the University of Bern in Switzerland.