Shifting Guidelines
By Rebecca Montz, EdD, MBA, CNMT, PET, RT(N)(CT), NMTCB RS
Radiology Today
Vol. 25 No. 7 P. 10
USPSTF Lowers Mammogram Age but Sparks Debate Over Screening Frequency
As personalized medicine advances, the question arises whether it is time to reassess and possibly overhaul breast screening guidelines to address diverse risk factors and improve early detection. Current breast cancer statistics underscore both the scale of the issue and existing disparities. According to the American Cancer Society (ACS), breast cancer is the most common cancer among women in the United States, comprising about 30% of new female cancer diagnoses. In 2024, there are expected to be 310,720 new cases of invasive breast cancer and 56,500 new cases of ductal carcinoma in situ, with a median diagnosis age of 62.
The CDC highlights disparities, noting that Black women experience higher breast cancer mortality rates than white women due to differences in health care access, socioeconomic factors, and tumor biology. They are also more likely to be diagnosed at a later stage, affecting survival rates. Hispanic women, while having lower incidence rates, are often diagnosed later, impacting their survival outcomes. These findings underscore the critical importance of addressing breast cancer outcomes for all populations.
While breast cancer remains a significant concern, with the ACS projecting approximately 42,250 deaths in the United States this year, notable advancements have been made in combating the disease. Death rates have been declining since 1989 due to advancements in screening, early detection, and treatment. These statistics emphasize the ongoing need for regular screenings, early detection efforts, and targeted interventions to reduce disparities and improve survival rates.
Updated USPSTF Guidelines
The United States Preventive Services Task Force (USPSTF) is one of many prominent independent organizations and panels responsible for establishing guidelines on breast cancer screening and other aspects of cancer care. Their recommendations play a crucial role in influencing insurance coverage and guiding health care providers in determining appropriate screening schedules for patients. In April 2024, the USPSTF updated its breast cancer screening recommendations, marking an advancement from previous guidelines. However, many organizations, including the ACR, believe that the new recommendations still fall short of what is needed to substantially improve life-saving outcomes.
The recent update to the USPSTF’s breast cancer screening guidelines introduced several notable changes. Women at average risk are now advised to begin regular mammograms at age 40 and continue through age 74, a shift from the previous starting age of 50. This adjustment is based on new evidence indicating that earlier screening can detect cancer at more treatable stages, aligning the guidelines more closely with those of other organizations. The USPSTF also recognized that Black women, who experience higher mortality rates from breast cancer and often face diagnoses in their 40s with more aggressive forms of the disease, may benefit from earlier screening. However, the task force acknowledged the need for further research to determine whether a distinct screening schedule is warranted for Black women.
Despite these advancements, the USPSTF maintained its recommendation for biennial screenings rather than the annual screenings endorsed by many other organizations. The guidelines also called for additional research into the effectiveness of breast ultrasound and MRI for women with dense breast tissue. Furthermore, the USPSTF’s updated recommendations lack specific guidelines for women aged 75 and older, citing insufficient data for making tailored recommendations for this age group. As a result, while the updated guidelines represent progress, there remains a need for continued evaluation and refinement to ensure that all women receive the most effective and personalized screening strategies.
Ongoing Concerns
Many organizations recognize that the USPSTF’s latest screening recommendations mark a significant advancement from earlier guidelines. However, despite this progress, these updates do not fully incorporate the comprehensive measures required to greatly enhance early detection and treatment outcomes. According to organizations such as the ACR, more refined and proactive screening protocols are necessary to address diverse risk factors and, more effectively, lower breast cancer mortality rates.
The ACR has reaffirmed its commitment to advocating for the USPSTF to recommend that all women undergo a breast cancer risk assessment by age 25, as specified in the ACR’s guidelines for high-risk women. Additionally, the ACR supports annual mammography screenings beginning at age 40 for women at average risk. This stance is echoed by the ACS, Society of Breast Imaging (SBI), and other organizations, all of which agree that annual screenings are the most effective method for saving lives.
Research highlighted by the ACR indicates that Black women, other minority women, and Ashkenazi Jewish women are more likely to develop and succumb to breast cancer before age 50 and possibly before 40 compared with non-Hispanic white women. The ACR’s 2021 guidelines for average-risk women and the 2023 guidelines for high-risk women emphasized that even a one-year delay in detection can have significant consequences for these groups.
The ACR and SBI advocate for continuing breast cancer screenings beyond age 74, provided severe comorbidities do not affect life expectancy, differing from the USPSTF’s stance. Additionally, there are concerns that the USPSTF did not address supplemental screenings, such as ultrasounds, contrast-enhanced mammography, and MRIs, which are effective for detecting cancer in younger women with dense breast tissue.
The differing perspectives underscore the ongoing debate over the most effective screening protocols to ensure optimal detection and treatment for all women. This debate highlights the need for continued research and dialogue to develop comprehensive guidelines that address the diverse needs and risks of all women, ultimately aiming to improve breast cancer outcomes across various demographics.
Screening Frequency and Methods
Stacy Smith-Foley, MD, the founding physician of The Breast Center at CARTI in Little Rock, Arkansas, emphasizes the importance of a comprehensive breast screening protocol for enhancing early detection and treatment outcomes. She advises women to engage in a detailed discussion with their health care provider around age 25 to evaluate their personal risk factors and family history. Although the USPSTF guidelines do not recommend risk assessments before age 40, the SBI guidelines advocate for early identification of high-risk individuals. Early assessments are essential for pinpointing those at greatest risk and customizing screening protocols to better suit their needs, Smith-Foley says.
Stamatia V. Destounis, MD, FACR, a breast imaging specialist at Elizabeth Wende Breast Care in Rochester, New York, and a member of Radiology Today’s editorial advisory board, agrees, asserting that annual routine mammography starting at age 40 is the only protocol proven to significantly reduce breast cancer mortality. She adds that assessing a patient’s risk status is crucial in determining the appropriate age and frequency for screenings and allows for a personalized screening regimen. Destounis supports continuing annual screenings as long as women remain in relatively good health and can undergo further diagnostic procedures and treatments if needed.
Claire L. Streibert, MD, site chief of breast imaging at Fox Chase Cancer Center in Philadelphia, says the ACR, National Comprehensive Cancer Network, and SBI have consistently advocated for annual screenings beginning at age 40 as the ideal approach for breast cancer screening. Radiologists, as leading experts in breast cancer imaging, have long advocated for this approach, with established guidelines consistently backing annual screenings from age 40, Smith-Foley notes.
Smith-Foley says the new USPSTF guidelines fall short by not recommending annual screenings despite evidence indicating that annual screenings for women aged 40 to 79 substantially reduce mortality compared with biennial screenings. Annual screening enhances early detection of breast cancer, she says, raising the likelihood of diagnosing the disease at a more treatable stage and resulting in a 99% five-year survival rate, as reported by the ACS. Moreover, the guidelines lack specifics on the optimal types of screening technology. Smith-Foley says 3D mammography is more effective than 2D mammography, detecting 20% to 65% more invasive cancers and reducing callbacks by up to 40%, according to a 2016 study in Lancet Oncology.
The USPSTF guidelines also lack recommendations for screening beyond age 75. Smith-Foley advises patients to continue scheduling mammograms as long as they can attend appointments, noting that breast cancer risk persists beyond age 75. Additionally, she encourages women to discuss their specific risk factors with their health care providers to consider the benefits of supplemental screening methods, which the task force did not address.
Cost-Benefit Analysis
Smith-Foley says the USPSTF’s new guideline recommending that breast cancer screenings begin at age 40 is a crucial and timely improvement, especially given the increasing incidence of breast cancer among women under 50 over the past two decades. She notes that early detection through routine screenings greatly enhances the likelihood of identifying cancer at a more treatable stage, leading to less invasive treatments and better long-term outcomes. Early detection not only makes treatment more manageable and costeffective but also significantly improves quality of life by reducing the need for aggressive therapies that can cause severe side effects and emotional distress. Destounis agrees, highlighting that early diagnosis minimizes the need for intensive treatments, which can result in job loss, difficulties in family care, and increased financial strain if patients are unable to work.
Streibert says that although there are upfront costs and additional tests such as imaging and biopsies, the benefits of early breast cancer detection—both in improving quality of life and reducing the need for costly interventions—far outweigh these initial expenses. She says early detection lowers morbidity and mortality rates by allowing for less invasive surgeries and milder treatments, such as chemotherapy. In the long run, reducing the costs associated with advanced cancer treatment is more cost-effective than having lower screening rates, she adds.
Specific patient groups, such as women with dense breast tissue or those with a calculated lifetime breast cancer risk of 20% or higher, can benefit from more intensive screening, Destounis says. She explains that incorporating supplemental tools such as ultrasound and breast MRI into routine breast screenings may lead to additional biopsies, but these methods can also uncover cancers that are not visible with mammograms alone. These imaging techniques have been proven effective in detecting otherwise hidden malignancies, she says.
Smith-Foley notes that most US insurance companies are required to cover annual breast cancer screenings for women starting at age 40. However, women at high risk for breast cancer, whether due to genetic factors, family history, or other reasons, often face challenges securing coverage for screenings before age 40. She says this gap in coverage needs urgent attention and correction by the USPSTF, as it places undue financial barriers on those who are at the highest risk.
Screening Disparities
The USPSTF’s decision to lower the breast cancer screening age to 40 offers significant potential benefits, particularly for Black women who face a higher risk of developing more aggressive cancers— such as triple-negative breast cancer—at younger ages, Smith-Foley says. Destounis notes the ACR’s recommendation that all women, particularly Black women, undergo a risk assessment by age 25. This early assessment is crucial for identifying those at higher-than-average risk and ensuring that appropriate screening measures are put in place.
According to a 2022 study, Black women are 40% more likely to die from breast cancer compared with white women, underscoring the critical need for effective screening methods. For example, while traditional 2D mammography has limitations in detecting abnormalities in dense breast tissue, 3D mammography provides detailed image slices that allow radiologists to examine breast tissue layer by layer, Smith-Foley says. Despite the widespread recognition of 3D mammography as the most effective screening method, a 2021 study points out that Black women undergo these screenings less frequently than their white counterparts. Destounis says that even though the disparity gap has been narrowing in recent years—likely due to increased awareness among health care providers and patients—Black women still experience lower rates of screening mammography.
Socioeconomic status significantly influences breast cancer screening rates among women, as those from lower income backgrounds often face barriers such as limited access to health care, fewer educational resources, and financial constraints that can hinder timely and regular screening. Access to screening mammography significantly affects screening rates, with transportation issues and health insurance being notable barriers, Streibert notes. To address these challenges, facilities such as Fox Chase Cancer Center employ a mobile mammography van to provide screening services directly to underserved communities.
Smith-Foley says socioeconomic disparities also affect patients’ ability to maintain a healthy diet and find exercise options— both crucial for reducing breast cancer risk—and limit educational opportunities. This lack of education can result in insufficient information about screening and prevention strategies. Addressing these multifaceted issues is essential for improving screening rates and reducing breast cancer disparities, ultimately leading to better health outcomes for women across all racial and socioeconomic backgrounds.
To improve outcomes, more aggressive screening protocols and broader recommendations are necessary, especially for higher-risk women. Streibert points out that annual mammograms can reduce mortality by nearly 40%. She advises women to evaluate their lifetime risk and consider genetic testing, which can help determine whether additional screenings are needed. Refining recommendations and focusing on personalized risk assessments are crucial for better breast cancer care and outcomes. Many organizations and health care providers believe the USPSTF guidelines do not adequately address diverse patient needs.
— Rebecca Montz, EdD, MBA, CNMT, PET, RT(N) (CT), NMTCB RS, has worked at the Mayo Clinic Jacksonville and University of Texas MD Anderson Cancer Center in Houston as a nuclear medicine and PET technologist.
