The U.S. Preventive Services Task Force’s latest draft recommendation on breast cancer screening is based in part on data on racial disparities in breast cancer mortality.
As a result, the task force has concluded that starting biennial screening at 40 will save more Black women.
“Black women are 40% more likely to die from breast cancer, compared to all women,” said USPSTF Vice Chair Wanda Nicholson. “This is a sobering statistic, and it’s an unacceptable statistic. And we have to make a change.”
USPSTF modeling estimates show that screening benefits for Black women are similar for breast cancer mortality reduction and greater for life-years gained and breast cancer deaths averted, compared with all women.
“Black women actually benefit even more from this recommendation,” Nicholson said. “For Black women, it’s about 1.8 additional lives saved for women screened over their lifetime.”
USPSTF acknowledges that there are no randomized controlled trials that have reported morbidity, mortality, or quality of life outcomes when comparing:
- Effectiveness of different ages to start or stop screening,
- Annual vs. biennial screening, and
- Screening with digital breast tomosynthesis vs. digital mammography.
A story about the task force’s draft recommendation, which proposes that women start biennial screening for breast cancer at age 40—instead of 50—appears here.
At the task force, we don’t deal with cost, and we don’t deal with insurance. Our goal, our single goal, is to help people across the nation to live healthier and longer lives.
“Research is needed to understand the underlying causes of the increased risk of breast cancer mortality in Black women, across the spectrum of stages and biomarker patterns,” USPSTF said in the draft recommendation.
Although the USPSTF analysis of health equity gaps focuses on Black women because they have the poorest health outcomes from breast cancer, the task force states that all studies should actively recruit enough women of all racial and ethnic groups to investigate whether the effectiveness of screening, diagnosis, and treatment vary by group.
“So, while screening is an important next step and we encourage Black women to proceed with our recommendation, we have to all recognize that there can be some inequities in the downstream steps,” Nicholson said.
“We’re not ever going to be able to screen our way out of this Black-white disparity in breast cancer deaths,” Nicholson said. “And those inequities have to be addressed for us to achieve that reduction in mortality that we all want to achieve.”
Nicholson spoke with Matthew Ong, associate editor of The Cancer Letter.
This conversation is also available as a video.
Matthew Ong: Thank you, Dr. Nicholson for joining us and talking about the updated recommendations for breast cancer screening today. Of note, in this updated recommendation is the expansion of the recommended age range for screening from 50 down to 40, and upgrading, from C to B, the lower age category. How has the evidence for screening women as young as 40 evolved since the 2002 recommendation, or maybe even since 2016?
Wanda Nicholson: Well, thank you for this opportunity to talk about our updated recommendation statement for breast cancer screening.
First of all, let me say that we know that breast cancer screening saves lives, and so we bring good news today, and we’re very pleased as the task force to bring this updated recommendation statement.
If you look at our prior recommendation from 2016, it did include women ages 40-49. We had that as a C recommendation, meaning that when we looked at mammograms every other year in that particular population age range of 40-49, we saw a small benefit.
And that was why, in 2016, we recommended that women within that age group talk to their physician in a one-to-one conversation to decide whether or not to proceed the screening at that time.
What we’ve done now in our updated 2023 recommendation is that we have additional science. We have new and more inclusive science that has enabled us to broaden our recommendation to recommend that women start screening at age 40, and continue every other year until age 49.
And that is because, now, with this new and more inclusive evidence, we see a moderate benefit to screening mammograms starting at age 40. So, that is the change that we are seeing in terms of the magnitude of benefit that has enabled us to broaden our recommendation to include starting women at age 40—all women—at age 40.
Speaking of the upgrading from limited benefit to moderate benefit, what does this mean for healthcare providers and their patients? In the 2016 recommendation, as you said, the task force emphasizes individual decision making for patients younger than 50. How should physicians and/or patients approach this now? Is it, “You’re now 40, we should start screening as per the latest USPSTF guidelines,” or, “You’re now 40, it’s an option”?
WN: Well, patients and their clinicians should start screening beginning at age 40.
So, if someone is 40 today, this is the day you start your mammogram screening—and welcome to the world of mammogram screening and saving lives. If you’re 41 or 42 and hadn’t previously obtained a mammogram, our response will be, “Let’s start right away and get you scheduled.”
Let me speak a bit about the additional new and inclusive science that allowed us to expand to women beginning at age 40. What we found is, first of all, using national population-based data, when we looked at the age range of 40-49, and we looked at SEER data, we found that, since 2000, between 2015 and 2019, there were more and more women than ever before that were being diagnosed with breast cancer between the ages of 40-49.
So, more and more women than ever before in that age range were being diagnosed with breast cancer.
And in fact, when you look, you’ll see that between 2015 and 2019, there was an approximately 2% annual increase each year, an annual increase of 2% in those years of incidence of breast cancer in this age range.
That was definitely an important and very impactful piece of information to have.
Our second resource, or area of data, was from the National Cancer Institute, and specifically the Breast Cancer Surveillance Consortium. And we have certainly used data from that dataset before, but we had updated data this time in that dataset, and therefore, had updated data to put into our modeling studies.
Our modeling studies is our third source of data, and it allows us to look at population trends and to look at topics of when to start screening, when to stop, and the intervals of screening. And we were able to use this updated data from the NCI to update our models.
So, all of that data collectively is what enabled us to then broaden that recommendation to say, all women should start at age 40, every other year until age 74.
This is a moderate benefit. And one important take-home point for your readers and your viewers is that by following this updated guideline, we can obtain up to a 20% breast cancer mortality reduction.
And that is very, very impactful on the lives of all women.
And I get that the totality of evidence is important here. Could we talk about the decision analysis for this recommendation? Specifically, the modeling estimates find that there would be 1.3 additional breast cancer deaths averted per 1,000 women for biennual screening starting at age 40? Could you talk about the considerations here in relying on this estimate, for instance, for expanding that screening age range? How are the benefits outweighing potential harms for women in this age category?
WN: Well, the primary benefit that we looked at was reduction in breast cancer deaths and looking at the number of lives saved.
And you’re correct, when we look at this screening strategy, it is 1.3 per 1,000 women screened over the lifetime of screening.
I think what’s also important, an additional statistic that’s important there, is particularly how it relates to Black women. Black women actually benefit even more from this recommendation. For Black women, it’s about 1.8 additional lives saved for women screened over their lifetime.
So, if you look at that 1.3 that you quoted, it corresponds to that overall 20% mortality reduction for all women. And then if you look particularly at Black women, it can be up to a 24% mortality reduction in that particular racial group. And so, again, all good news in this recommendation statement of starting at 40 and every other year can save lives.
The latest recommendations do make an important point of looking at these disparities in breast cancer mortality by race, and you’ve talked about some of it. What are the other takeaways here? I do see that there is a 40% increased risk of dying from breast cancer for Black women, specifically.
WN: Well, you’re exactly right. Black women are 40% more likely to die from breast cancer compared to all women. And this is a sobering statistic, and it’s an unacceptable statistic. And we have to make a change.
The task force has been, and always will be, committed to looking at how our recommendations can impact disparities and close the gap in depths among minority populations. That is definitely a priority of the task force.
And this is definitely one of those recommendation statements that we believe help to achieve that. So, as we mentioned earlier, a 20% reduction in mortality overall, and about a 24% reduction among Black women.
Our take-home message to Black women would be, be encouraged to follow these guidelines. Start at age 40, get to your clinician, every other year, until age 74.
But what I would also say, not just to Black women, but to us as a whole, is that screening is so, so very important, and it is a crucial first step.
But we’re not ever going to be able to screen our way out of this Black-white disparity in breast cancer deaths. We must ensure that other inequities that can occur in the healthcare system—for example, Black women may be screened with mammograms, but in many cases, there can be delays when there’s an abnormal mammogram in terms of follow up.
Sometimes Black women do not always get the indicated biopsy in a timely fashion, and they also need access to equitable treatments.
So, while screening is an important next step and we encourage Black women to proceed with our recommendation, we have to all recognize that there can be some inequities in the downstream steps.
And those inequities have to be addressed for us to achieve that reduction in mortality that we all want to achieve.
I was just writing a story two weeks ago about the breast cancer mortality disparity in D.C. between white and Black women, and I think it’s 3.3 times more for Black women. Also to your point, about potentially poor quality screening for mammograms for many women, especially underserved communities, I think there’s another data point where only 63% of women age 50 and above were up to date for mammography screening. Could you talk about how all of these things combined indicate that there is an area of unfulfilled or unmet need in terms of awareness about screening?
WN: Well, a couple of things. We’re always encouraging women to pursue having their mammograms and getting them in a timely manner.
When you actually look at overall statistics, you’ll actually see that Black women actually complete their mammograms at a similar rate to all women.
So, there may be some gaps there, but not major gaps as we see it.
Of course, we also know that we recognize that there can be women who may live in more underserved areas, and particularly in rural areas, who may have some challenges to being able to access mammograms in a timely fashion.
And we would call upon the healthcare system, healthcare policymakers to really focus on trying to reduce those inequities.
But having said that, again, mammograms are so important. They are an important first step. And women should start at age 40 and continue every year until age 74.
But we also must address the inequities within the healthcare system so that once an abnormal mammogram is identified, subsequent steps in breast cancer care do occur, and occur in a timely fashion.
Here are a couple of due diligence questions: I do remember the contention over the 2016 recommendations when there was this Mandl et al. Health Affairs paper that estimated that the U.S. spends $4 billion a year on unnecessary mammograms for women between the ages of 40-59 (The Cancer Letter, April 24, 2015). Is this still a consideration at all?
WN: At the task force, we don’t deal with cost, and we don’t deal with insurance.
Our goal, our single goal, is to help people across the nation to live healthier and longer lives. We wake up every day with that mission and vision in hand.
And so, our goal is to look at the best available science, the best available evidence that we can find, and to make recommendations based on the evidence.
All Americans deserve the best recommendations that we’re able to provide, and being able to help them to live longer and healthier lives.
So, that’s our primary focus.
Right. And I hate to belabor the point about totality of evidence, but as some people might say, RCTs are the gold standard for basing recommendations on, and the task force acknowledges that there are no RCTs comparing starting or stopping screening at different ages. Are there any RCTs demonstrating benefits of mammography for women in their 40s, or is that a limited way of looking at evidence?
WN: Well, there are some older studies back in the days of film mammography that actually do include women in their 40s in those early trials.
So, we know from those early trials that those trials actually serve as the foundational evidence that we need to know that mammograms do make a difference in saving lives. There are some women in the 40-49 year range that are in those early, early trials.
Now, again, they were done with film mammography. What you have to think about now is that now, fortunately, we have advances in mammography techniques. We have digital mammography, and we also have DBT, or 3D, mammography.
What we don’t have clinical trials is in annual versus every other year screening. Those trials we don’t have. And that’s why the task force focuses, at least at this juncture at this time, on modeling studies and data input into our modeling studies to help us to be able to look at the potential benefits as well as harms of different screening strategies, which we did in preparation for this recommendation statement.
I did see the commissioned report from Kaiser, if I’m not mistaken. Do you think the HHS should adopt these updated guidelines over the current one that is still in use, the 2002 recommendation? It seems to me a significant difference in those recommendations is the recommendation for biennial, instead of annual, screening.
WN: So, the task force recommendations from 2016 and 2009 are very similar.
They were B recommendations in women 50 and older, and then the C recommendation for those 40-49. As I indicated, we have new more inclusive science that has allowed us to expand it for a new recommendation, where we expand it so that all women, starting at age 40, are screened every other year until age 74.
So, the change in this recommendation from 2016 is that, rather than women having a selective conversation with their providers, that we’re saying that all women should start at 40 and continue every other year until age 74. So that includes women ages 50-74, but also continue to have mammograms every other year.
Here’s a policy question: Given the recent ruling in a Texas District Court that eliminates zero cost-sharing for preventive services—I know the task force does not deal with costs—but in your opinion, what do you expect the cumulative harm to the American public would be if all of these cancer screenings that are recommended by the task force were no longer fully covered by insurance providers?
WN: Well, we are aware of the Braidwood case, and certainly following that, but what I would say, again, is that our single-handed mission is to help people across the nation to live longer and healthier lives. And that will remain our focus.
We are continuing to do our work, as you can see from us talking extensively about this breast cancer recommendation. And we will continue that today, tomorrow, and into next week and next month. That’s our sole purpose.
Do you think we missed anything?
WN: I do want to cover two additional areas within our recommendation statement that are important for your readers to know about, because they are areas in which we were not able to make a clear recommendation at this particular time.
Mammograms are so important. They are an important first step. And women should start at age 40 and continue every year until age 74. But we also must address the inequities within the healthcare system so that once an abnormal mammogram is identified, subsequent steps in breast cancer care do occur, and occur in a timely fashion.
One is the very important topic of dense breast. More than 50% of women in the U.S. have dense breasts, and we know that women with dense breasts are at higher risk for breast cancer.
And we also know that it can be more challenging at times, that mammograms may not work quite as well in this particular population.
So, one of the questions we had for this recommendation statement was whether or not women with dense breasts needed additional imaging in addition to mammograms, such as an ultrasound or an MRI. And we looked, and we looked, and we looked, and I have to say, the task force was frustrated that we were not able to find sufficient evidence at this particular time in our evidence report to be able to make a recommendation for or against supplemental screening along with the mammogram in women with dense breasts.
We are urgently calling for more research in this area. You’ll see that outlined in our draft recommendation statement. And so, in the interim time, we’re recommending that women have that one-to-one conversation with their trusted clinician about what their next steps should be.
Another important group are women who are 75 years of age and older. And as I often say, if we look across our family tree, we see plenty of women who are in that age range, our moms, our grandmothers, our aunts, and we want to continue to see them at these family events. And the task force wants you to continue to see them at these family events.
But currently, we do not have sufficient evidence for what is the best recommended screening in that age group. There are no clinical trials in that group. So, again, we are calling urgently for more research, and in the interim time, recommending that women in that age range, again, have that one-to-one conversation with their provider about what screening is best for them.
Dr. Nicholson, thank you so much for your time.
WN: Thank you so much as well. Good to see you today.
