Opinion | Proposed Breast Cancer Screening Guidelines Are Good, but Not Enough

The U.S. Preventive Services Task Force (USPSTF) has proposed new breast cancer screening guidelines for the first time in 14 years.

The current guidelines, first published in 2009 and again in 2016, recommend biennial screening mammography for women ages 50 to 74 years, and state that the decision to start screening in women younger than 50 years should be an individual one. The new proposed guidelines have some important changes for younger women, but there are still opportunities for improvement, especially for older women, those with dense breasts, and Black women.

The new draft guidelines recommend that all women get screened for breast cancer every other year, starting at age 40. That’s an important change. Breast cancer affects one in eight women in the U.S. and occurs in every decade of life. Approximately 9% of all breast cancers occur in women under 45 years of age. Lowering the screening age from 50 to 40 can save the lives of women in their 40s.

Unfortunately, however, the proposed guidelines continue to recommend screening every 2 years, rather than every year. Research has shown that yearly mammography starting at age 40 saves more lives — reducing breast cancer mortality by up to 40% compared to no screening. Having mammograms yearly, instead of every other year, helps find cancers when they are smaller and easier to treat, which may reduce the need for aggressive treatments, like mastectomy and chemotherapy.

Another limitation of the new draft guidelines is the lack of detailed evidence-based guidance for older women. As with the current guidelines, the Task Force recommends breast cancer screening only until age 74, and states that there is insufficient evidence to assess the balance of benefits and harms of screening in women 75 and older.

However, breast cancer remains a threat in women 75 and older, and many women today are experiencing a high quality of life into their 80s and even 90s. Until there is enough research to support a screening recommendation, older women will need to decide together with their clinicians what is best for their individual health needs, based on their preferences, values, and health history. More research in this age group is essential.

In their new draft statement, the USPSTF specifically recognizes the importance of dense breasts. About half of all U.S. women have dense breast tissue. Breast density is important because women with dense breasts are at increased risk for breast cancer. Plus, dense breasts make mammograms harder to read, which means that some breast cancers may not be detected.

Despite acknowledging the risks associated with dense breasts, the Task Force stopped short of recommending supplemental screening, saying that more research is needed before they can make a recommendation. Published studies, however, have already demonstrated that both breast ultrasound and MRI can increase cancer detection in women with dense breast tissue. In March, the FDA updated regulations to require that all women having mammograms be notified of their breast density. Mammogram providers have to implement the new standards within 18 months. Women with dense breasts and their doctors need guidance about what additional testing they need. They won’t be able to find that guidance in the USPSTF’s proposed recommendations.

Finally, the USPSTF recognized the increased breast cancer risk among Black women and called for more research about breast cancer health disparities. That’s important because Black women are 40% more likely to die of breast cancer, and more likely to get aggressive breast cancers at young ages. The USPSTF asserts in their new draft statement that lowering the screening age to 40 will help reduce some of the disparity and urges further research.

The Task Force could have taken steps to reduce some of the disparity right now. Many Black women are not aware of their increased risk. Risk assessment and education should be recommended for all women before the age of 30, especially for Black women and other ethnic groups who are at increased risk. Universal risk assessment could identify high-risk women and allow them to partner with their doctors to personalize their screening. Some of these women may need to start screening as early as age 25-30, and may benefit from additional testing beyond mammography, such as MRI.

Overall, these proposed guidelines are a step in the right direction, and the Task Force seems to be taking a broader approach in its consideration of breast cancer screening. But there is an opportunity to make these recommendations better, particularly for older women, those with dense breasts, and Black women.

The USPSTF is calling for more research. Unfortunately, these women need guidance today. Their lives may depend on it.

Nina Vincoff, MD, is medical director for the Katz Institute for Women’s Health and Breast Imaging Division chief at Northwell Health.