Details on the new recommendation

In 2009, USPSTF raised the recommended age for routine mammograms from 40 to 50, arguing that earlier screenings would do more harm than good and lead to unnecessary treatment in women who receive false positive biopsies.

However, recent trends — including an increase in the number of cancers diagnosed among women under the age of 40 — troubled the task force. According to USPSTF, breast cancer diagnoses among women in their 40s had been increasing by less than 1% between 2000 and 2015 but rose by 2% each year on average between 2015 and 2019.

"We don't really know why there has been an increase in breast cancer among women in their 40s," said Carol Mangione, previous chair of USPSTF. "But when more people in a certain age group are getting a condition, then screening of that group is going to be more impactful."

The new recommendation that women begin regular, biennial screenings starting at age 40, applies to all "cisgender women and other people assigned female at birth," USPSTF said. It does not apply to people who have previously had breast cancer, carry genetic mutations that increase their risk of breast cancer, have had breast lesions previously identified in biopsies, or have had high-dose radiation to their chest. Those women should talk to their doctor about how frequently they should be screened, the task force said.

USPSTF especially emphasized that Black women begin getting mammograms at age 40, as they are more likely to get aggressive tumors at a young age and 40% more likely to die from breast cancer than white women.

Mangione said she believes the new recommendations can significantly reduce breast cancer mortality. "If all women followed our new recommendation, we could reduce mortality from breast cancer in the U.S. by about 20%," she said. "That's a big reduction in mortality from breast cancer."

Mangione added that USPSTF "looked hard" to determine if annual screenings would save more lives than biennial screenings, but for now, "we found that every other year was the optimal strategy," though she added that more evidence is needed.

The draft recommendation is open for public comment until June 5, 2023.

Reaction

Some experts praised USPSTF's new recommendation, with Laura Dominici, a breast cancer surgeon at  Dana Farber/Brigham and Women's Cancer Center, saying the new guidelines incorporate "more modern and 'real world' data into the science informing the guidelines and will hopefully prompt payers to provide better coverage for women seeking breast cancer screening."

"This is particularly important related to racial disparities in screening, as Black women are more likely to develop aggressive cancers at younger ages, contributing to worse outcomes," Dominici added. "I am glad to see inequities in screening being acknowledged, but more attention to this will be needed in future guidelines."

"Whatever we can do to get more women screened for breast cancer is a good thing," said William Dahut, chief scientific officer for the American Cancer Society.

"We think lots of women are currently being screened in their early 40s, so as the guidelines become more consistent, I think that makes it easier," he added.

However, some experts were concerned about the new recommendations. Rita Redberg, editor-in-chief of  JAMA Internal Medicine  and a cardiologist at the University of California, San Francisco, said it's "concerning to see a lowering of the age to start mammography," adding that USPSTF failed to show the benefits of screening starting at age 40 "will outweigh the harms of the practice."

Ruth Etzionoi, a biostatistician who studies cancer screenings at the Fred Hutchinson Cancer Center, said she thinks "people are going to be surprised" by the new recommendations.

"Change always happens over time, obviously, as the evidence evolves. At the same time, there needs to be a compelling reason and in the materials here, I don't see a compelling reason yet," she said, adding that when she looked at 2016 modeling studies, "the harm-benefit analysis was very similar."

Other experts were specifically concerned with the recommendation that women receive biennial screenings rather than annual ones. Michele Blackwood, chief of breast surgery at Rutgers Cancer Institute of New Jersey, said the new recommendations are "worrisome."

"Most of us in this realm still vociferously support yearly mammograms for women over age 40," she said.

"It's estimated that about 300,000 new cases will be diagnosed this year, but breast cancer numbers are not going down," said Ryland Gore, a breast surgical oncologist in Atlanta. "Imagine how many you potentially miss by saying, 'Oh, you can just do this every other year.' That is not good enough."

Debra Monticciolo, from  Massachusetts General Hospital and a member of the board of directors at the  Society of Breast Imaging, said she was "disappointed" by the new recommendations.

"Even if you look at their own data, annual screening results in more deaths averted, no matter what type of screening program you put in those models," she said.

"Unfortunately, the fact that they're still recommending every other year rather than yearly screening, and in particular in the younger population, is very disappointing," said Maxine Jochelson, chief of the breast imaging service at Memorial Sloan Kettering Cancer Center.

"You are going to miss earlier cancers if you're waiting longer, and younger women and Black women often have more aggressive cancer," she added. "I'm going to still tell them to have yearly screening." (Rabin, New York Times, 5/9 [1]; Rabin, New York Times, 5/9 [2]; Aubrey, "Shots," NPR, 5/9; Howard, CNN, 5/9; Chen, STAT, 5/9; Hassanein, USA Today, 5/9; Bassett, MedPage Today, 5/9)