USPSTF Recommends Breast Cancer Screening Starting at Age 40

"To achieve the benefit of screening and mitigate disparities in breast cancer mortality by race and ethnicity, it is important that all persons with abnormal screening mammography findings receive equitable and appropriate follow-up evaluation and additional testing, inclusive of indicated biopsies, and that all persons diagnosed with breast cancer receive effective treatment," according to the authors of the recommendation statement.

Individuals as young as 40 years should undergo screening for potential breast cancer, according to a recommendation statement that the United States Preventive Services Task Force (USPSTF) published in JAMA.¹

Specifically, the USPSTF stated that there is adequate evidence supporting the moderate benefit of biennial screening mammography in reducing breast cancer mortality among individuals who are 40 to 74 years old. Regarding other recommendations in the statement, current evidence appears to be insufficient in support of the benefits over the potential harms of screening mammography in those who are 75 years and older. Additionally, limited evidence highlights the potential benefits and harms of supplemental breast cancer screening via breast ultrasonography or MRI in those with dense breasts and a negative screening mammogram.

As part of putting these recommendations into practice, the USPSTF stated that both digital mammography and digital breast tomosynthesis (DBT) are suitable modalities. Additionally, it is recommended that clinicians should exercise their judgment as to whether they should conduct screening for breast cancer in individuals who are 75 years and older or use supplemental screening for those with dense breasts and a mammogram that appears to be normal.

“To achieve the benefit of screening and mitigate disparities in breast cancer mortality by race and ethnicity, it is important that all persons with abnormal screening mammography findings receive equitable and appropriate follow-up evaluation and additional testing, inclusive of indicated biopsies, and that all persons diagnosed with breast cancer receive effective treatment,” the authors wrote.

The USPSTF previously issued a recommendation on the use of breast cancer screening in 2016, in which the organization supported biennial screening mammography for individuals who are 50 to 74 years old while individualizing screening decisions for those 40 to 49 years old. As part of its follow-up to the 2016 recommendation, the USPSTF conducted a systematic review comparing the efficacy of various mammography-based strategies with respect to factors including the age of initiating and ending screening, screening interval, modality, use of supplemental imaging, and personalization of screening. Additionally, collaborative modeling studies from various Cancer Intervention and Surveillance Modeling Network modeling teams were intended to complement the evidence from the systematic review.

Findings from a meta-analysis conducted in support of the 2016 breast cancer screening recommendation highlighted a reduced risk of breast cancer mortality with screening mammography for those who are 39 to 49 years old (relative risk [RR], 0.88; 95% CI, 0.73-1.00), 50 to 59 years old (RR, 0.86; 95% CI, 0.68-0.97), and 60 to 69 years old (RR, 0.67; 95% CI, 0.54-0.83).² Additionally, an updated analysis of 3 screening trials in Sweden indicated a relative reduction in the risk of breast cancer mortality by 15% among those who are 40 to 74 years old (RR, 0.85; 95% CI, 0.73-0.98).³

Data from collaborative modeling indicated that initiating biennial screening at 40 years old compared with ages 50 to 74 years old would avert 1.3 additional deaths from breast cancer per 1000 women over a lifetime of screening. Additionally, the screening benefits related to breast cancer mortality reduction and deaths averted in Black patients were comparable with outcomes observed across the general population.

According to collaborative modeling, biennial screening conferred higher incremental life-years gained and reductions in mortality per mammogram while eliciting a more favorable balance of benefits vs annual screening. Authors noted that there is limited trial or observational evidence suggesting that screening any group of individuals annually rather than biennially improves breast cancer mortality rates.⁴

The systematic review did not identify any randomized clinical trials or observational studies assessing screening with DBT vs digital mammography and how the modality impacted morbidity, mortality, or quality of life. Additionally, collaborative modeling findings highlighted similar benefits with DBT compared with digital mammography.

No studies evaluating supplemental screening with MRI or ultrasonography as well as personalized screening strategies that reported on morbidity, mortality, or cancer detection or characteristics were identified. Collaborative modeling estimated that screening mammography may be more beneficial for individuals at a modestly increased risk of disease.

Regarding potential gaps in research needs for breast cancer screening, the authors noted that research is necessary for understanding and addressing a higher incidence of breast cancer mortality among Black individuals. For example, findings are needed to address why this population is more probable to have a breast cancer diagnosis with biomarker patterns that confer a higher risk for poor health outcomes.

Authors stated that all studies should actively enroll individuals of all racial and ethnic groups—including Asian, Black, Hispanic, Native American, and Pacific Islander individuals—to evaluate how the efficacy of screening, diagnosis, and treatment may differ across different populations.

“Disparities in follow-up after screening and treatment have been observed for Asian, Black, and Hispanic women,” the authors wrote. “Improvements in access to effective health care, removal of financial barriers, and use of support services to ensure equitable follow-up after screening and timely and effective treatment of breast cancer have the potential to reduce mortality for individuals experiencing disparities related to racism, rural location, low income, or other factors associated with lower breast cancer survival.”

References

1. US Preventive Services Task Force. Screening for breast cancer: US Preventive Services Task Force recommendation statement. JAMA. Published online April 30, 2024. doi:10.1001/jama.2024.5534
2. Nelson HD, Cantor A, Humphrey L, et al. Screening for breast cancer: a systematic review to update the 2009 US Preventive Services Task Force recommendation. Evidence Synthesis. No.124. Agency for Healthcare Research and Quality; 2016. AHRQ publication 14-05201-EF-1.
3. Nyström L, Bjurstam N, Jonsson H, Zackrisson S, Frisell J. Reduced breast cancer mortality after 20+ years of follow-up in the Swedish randomized controlled mammography trials in Malmö, Stockholm, and Göteborg. JMedScreen. 2017;24(1):34-42. doi:10.1177/0969141316648987
4. Henderson JT, Webber EM, Weyrich M, Miller M, Melnikow J. Screening for breast cancer: a comparative effectiveness review for the US Preventive Services Task Force. Evidence Synthesis No. 231. Agency for Healthcare Research and Quality; 2024. AHRQ publication 23-05303-EF-1.