Women should begin mammogram screenings at 40 years old instead of waiting until 50, according to new recommendations from the U.S. Preventive Services Task Force (USPSTF).
Published on April 30 in JAMA, these updated guidelines aim to improve early detection of breast cancer.
The guidelines are intended for women of average risk for breast cancer. Women at very high risk due to genetic factors or other conditions may need to start screening earlier. The new recommendations state that women should get mammograms starting at age 40 and continue every year through age 74.
The previous 2016 guidelines recommended that women with average risk start breast cancer screening at 50, with women aged 40 to 49 discussing screening options with their doctors.
The change in guidelines is significant due to the increasing rates of breast cancer among women in their forties. According to Wanda Nicholson, M.D., M.P.H., M.B.A., Task Force Chair and professor at the Milken Institute School of Public Health at The George Washington University, “By starting to screen all women at age 40, we can save nearly 20 percent more lives from breast cancer overall.”
Most Experts Believe Women Should Get Annual Mammograms
Despite the lowered age recommendation, some experts argue that the guidelines do not go far enough. Parisa Lotfi, MD, an assistant professor of radiology at Yale Cancer Center, believes, that annual screenings are necessary to save the most lives.
“Studies support annual screening to save the maximum number of lives. The task force fell short in that it is recommending mammography every two years,” says Dr. Lotfi.
In the new guideline statement, the committee acknowledged that it received several comments that “expressed that breast cancer screening should be recommended annually.”
The USPSTF acknowledged receiving public comments advocating for annual screenings but stated that there are no randomized trials comparing the effectiveness of annual versus biennial screenings. They concluded that biennial screening “results in greater life-years gained and mortality reduction per mammogram and has a more favorable balance of benefits to harms compared with annual screening.”
Natasha Monga, MD, an assistant clinical professor of radiology at The Ohio State University Comprehensive Cancer Center in Columbus, also believes that the recommendation for biennial screening is insufficient.
“Annual screening mammography saves the most lives and is recommended by many major medical organizations. In fact, the USPSTF, American Cancer Society, and many others agree that annual screening mammography decreases breast cancer mortality,” says Dr. Monga.
Yearly Mammograms are Covered by Obamacare and Most Insurance Companies
Fortunately, the Affordable Care Act (Obamacare) and most health insurance plans cover the cost of annual mammograms. This means that women aged 40 and over can opt for yearly screenings despite the USPSTF’s every two years recommendation.
However, mixed messages from various sources can create confusion for patients. “The mixed messages – coming from the various sources such as physicians, the media, and the task force – can create confusion for the patients who don’t know what recommendations to follow,” says Dr. Lotfi.
Breast Cancer Deaths Reduced by Mammograms by 40 Percent
“Mammograms do not prevent cancer, however screening allows for early detection of small cancers that are readily treatable and often curable with excellent long term outcomes,” says Dr. Lotfi.
Breast cancer accounts for an estimated 30 percent of all new female cancers each year, with a 1 in 8 chance that a woman will develop breast cancer in her lifetime.
Since 1990, mammograms have helped reduce breast cancer deaths in the United States by nearly 40 percent, according to the American College of Radiology.
Screening has been shown to reduce the risk of dying from breast cancer by nearly half.
Starting Mammography at Age 40 Could Especially Benefit Black Women
The updated guidelines are especially beneficial for Black women, who have a higher mortality rate from breast cancer. “This new approach has even greater potential benefit for Black women, who are much more likely to die of breast cancer,” said Dr. Nicholson.
Black women are 40 percent more likely to die of breast cancer compared with white women and are often diagnosed with more aggressive forms of the disease.
Additionally, these women are more likely to be diagnosed with advanced-stage and more aggressive forms of breast cancers, says Monga. “This makes annual screening mammography starting at age 40 even more essential for these patients,” she says.
The authors of the report noted that while this recommendation is an important first step, more work is needed to address the existing inequities.
Guidelines for High-Risk Women
The new guidelines do not apply to women at high risk for breast cancer, explains Dr. Monga.
“There are many factors that increase the risk for breast cancer, including genetic mutations, family history, chest radiation at a young age, personal history of breast cancer, breast density, and race or ethnicity,” she says.
Women who fall into this higher risk group may be recommended to start earlier, more intensive screening. “The American College of Radiology recommends that all women should undergo breast cancer risk assessment by age 25, especially for Black women and those of Ashkenazi Jewish descent,” says Dr. Monga.
Committee Neglects Recommending Additional Screening for Women with Dense Breasts
Nearly half of women over 40 have dense breasts, which is a risk factor for breast cancer.
Dense breasts can also complicate mammogram interpretations, increasing the likelihood of missed cancer detections.
Therefore, supplemental screening, such as ultrasound or breast MRI, can be beneficial for detecting cancers that mammograms may not reveal, according to Dr. Monga.
However, the task force concluded that more evidence is required before they can recommend supplemental screening.
“Since the task force’s recommendations drive the insurance companies’ policies, this will make it harder for patients to get access to these tests,” says Dr. Lotfi.
Certain States Cover Extra Testing for Women With Dense Breasts
According to Dr. Monga, many states have passed legislation to eliminate patient cost-sharing for supplemental screening, meaning no out-of-pocket costs, to improve access to these tests. To see if your state is one of them, check out the map from Dense Breast-info.
“Additionally, the Find It Early Act, introduced nationally, aims to eliminate patient cost-sharing for supplemental screening for women with dense breasts for all health insurance providers,” she says.
As March 2023 update from the U.S. Food and Drug Administration (FDA) mandates that all women in the U.S. must be informed about the density of their breasts. Mammogram provides are required to implement these new standards by September 10, 2024.
If you’ve been notified that you have dense breasts, discuss with your provider whether you should have supplemental testing along with your mammograms.
Screening Recommendations for Women Over 75 Years Old
The task force recommends that women get mammograms until age 74. However, Dr. Lotfi believes this age limit is too restrictive.
“There are millions of women over the age of 75 who are in excellent health with a life expectancy of many more years, whose risk for developing breast cancer remains high after 75. The task force did not adjust to incorporate this group of women,” she says.
The American College of Obstetricians and Gynecologists (ACOG) advises women over 75 to make a shared decision with their doctors about continuing mammograms.
The American College of Radiology and the Society of Breast Imaging both recommend continued screening after age 74 unless severe co-existing conditions limit life expectancy.
The updated USPSTF guidelines lowering the starting age for mammograms to 40 mark an important step in breast cancer prevention. While the every two years screening recommendation has drawn some criticism, the option for annual screenings remains available through most insurance plans.
As breast cancer rates rise, particularly among younger and Black women, early detection through regular mammograms becomes increasingly vital. Women should discuss their individual risk factors and screening options with their healthcare providers to make informed decisions about their breast health.
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