Alarmed by a rise in breast cancer diagnoses among young women and persistently high death rates among black women in particular, health experts on Tuesday proposed a stark overhaul of standard medical advice on mammograms.
Women of all racial and ethnic backgrounds who are at average risk for breast cancer should start having regular mammograms at age 40 instead of waiting until age 50 as previously recommended, the US Preventive Services Task has said. Strength.
The group publishes influential guidelines on preventive health, and its recommendations are generally widely adopted in the United States. But the new notice, released in draft form, represents something of a reversal.
In 2009, the USPSTF raised the age for starting routine mammograms from 40 to 50. At the time, researchers feared that early detection could do more harm than good, leading to unnecessary treatments in young women, including biopsies that turn out to be negative.
But there have been troubling trends in breast cancer in recent years. They include an apparent increase in the number of cancers diagnosed in women under 50 and a failure to close the survival gap for young black women, who die of breast cancer at twice the rate of white women of the same age.
“We don’t really know why there has been an increase in breast cancer among women in their 40s,” Dr. Carol Mangione, the task force’s outgoing chair, said in an interview. “But when more people in a certain age group have a disease, screening that group will have more impact.”
The new recommendation covers more than 20 million women in the United States between the ages of 40 and 49. In 2019, about 60% of women in this age group reported having had a mammogram in the past two years, compared to 76% of women aged 50-64 and 78% of women aged 65-74.
The panel said there was not enough evidence to make recommendations one way or the other for women aged 75 and over.
Dr. Mangione said the USPSTF had for the first time commissioned studies of breast cancer specifically in black women, as well as for all women, and needed more research into the factors behind it. racial disparity. The task force also calls for a clinical trial to compare the effectiveness of annual and biannual screening in black women.
Overall, breast cancer mortality has declined in recent years. Yet it remains the second most common cancer in women after skin cancer and the second leading cause of cancer death, after lung cancer, among women in the United States.
Breast cancer diagnoses among women in their 40s had increased by less than 1% between 2000 and 2015. But the rate increased by 2% per year on average between 2015 and 2019, the task force noted.
The reasons are not entirely clear. Postponing childbearing, or not having children at all, could fuel the rise, said Rebecca Siegel, senior scientific director of surveillance research at the American Cancer Society. Having children before age 35 reduces the risk of breast cancer, as does breastfeeding.
Still, she noted, there is great year-to-year variation in diagnosis rates. Other researchers suggest the increase in younger women may simply reflect more screening, said Dr Steven Woloshin, professor of medicine at Dartmouth University.
Frequent screening can itself cause harm, leading to unnecessary biopsies that cause anxiety and treatment for slow-growing cancers that would never have been life-threatening, the researchers found.
Still, there was a storm of criticism in 2009, from both patients and advocacy groups, when the task force advised that only women over 50 get regular mammograms. Critics of this guidance worried that malignancies were being missed in young women and suggested that a desire to reduce health care costs was behind the recommendation.
At the time, the committee also called for longer intervals between mammograms: one every two years, rather than annual scans. This recommendation still stands.
The American Cancer Society differs on this key point. Women between the ages of 40 and 44 should be able to choose screening, the society says, but from age 45 women should have mammograms every year until age 55, when breast cancer risk begins to decline.
Karen E. Knudsen, executive director of the ACS, said she welcomes the task force’s advice to begin routine screening at a younger age, as it will alleviate confusion resulting from conflicting recommendations from medical groups.
Still, she said, “We stick with annual screening. Cancers in premenopausal women grow faster, and it’s important that they don’t grow over the two-year period and go unnoticed.
The task force’s new recommendation applies to all people assigned at birth who are asymptomatic and at average risk of breast cancer, including those with dense breast tissue and a family history of breast cancer.
But the advice does not apply to anyone who has had breast cancer before, who carries genetic mutations that increase their risk, who has had breast lesions identified in previous biopsies, or who has received high-frequency radiotherapy. dose on the chest, which increases the risk of cancer.
These women should consult their doctor about how often to get tested.
The task force stressed that it was important for black women to start mammograms at age 40 because they are more likely to have aggressive tumors at a young age and 40% more likely to die of breast cancer. than white women.
Some scientists have called for a move away from a one-size-fits-all, one-size-fits-all approach to screening in favor of a “risk-tailored” approach, which would mean screening black women six to eight years earlier than white women.
“The recommendation should be tailored based on race and ethnicity to maximize the benefits of screening and minimize its harms and address the current racial disparity,” said Dr Mahdi Fallah, who studies HIV prevention. risk-adapted cancer at the German Cancer Research Center in Heidelberg. .
But screening alone won’t improve survival rates for black women, who are not only more likely to develop aggressive tumors, but also struggle with delays in seeking medical care and life circumstances. which make treatment difficult.
The new task force report found, for example, that while follow-up to abnormal breast scans is often delayed, this is especially true for black women.
“So often when it comes to a black woman, you hear a narrative you wish you didn’t hear,” Dr. Mangione said.
“A lot of times it’s women who themselves find a lump or discharge that they know is abnormal, and they come in and get fired. And that’s only because they’re not willing to take no for an answer. that they are finally diagnosed.