#448 USPSTF Breast Cancer Screening

July 10, 2024 | By Fatima Syed

Audio

Video

Transcript available via YouTube

Updated recommendations and the reasoning behind them

In this episode of The Curbsiders Podcast, the team delves into the recently updated breast cancer screening recommendations from the U.S. Preventive Services Task Force (USPSTF) with Dr. Wanda Nicholson (@wnicholsonobgyn), an expert in preventive medicine, diversity, equity and inclusion, and women’s health and the Chair of the Task Force.  Join us as we review the newest screening mammography recommendations, evidence for earlier screening for all women, the challenge of dense breast findings, and more. Importantly, we discuss disparities in breast cancer outcomes and the need to better understand and address them.

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Show Segments

• Intro and Guest Background
• Case
• Updated Breast Cancer Screening Recommendations
• Rationale for screening age
• Considerations for findings of dense breasts
• Balancing benefits and harms
• Racial disparities
• Research Gaps
• Outro

USPSTF Breast Cancer Screening Pearls

1. The USPSTF recommends biennial (every 2 year) breast cancer screening mammography for women aged 40-75, and evidence is insufficient for women aged 75 and older. (USPSTF, 2024)
2. Breast cancer incidence is increasing in younger women, and modeling suggests this earlier age of screening initiation (40 vs 50) averts an additional 1.3 deaths per 1000 women screened. (Trentham-Dietz, 2024)
3. There is insufficient evidence to recommend additional supplemental screening for women with screening mammography showing dense breasts and otherwise negative; this is a research priority to assess benefits and risks for patients.
4. Understanding and addressing disparities is a central focus of this update, as Black women have a 40% higher mortality from breast cancer despite similar screening rates, as compared to White women.

USPSTF Breast Cancer Screening Show Notes

What is the Task Force recommending? (USPSTF, 2024)

For women aged 40-74, the USPSTF recommends biennial (every two years) screening mammography (grade B recommendation).

•  Changes to age of screening initiation: Prior 2016 USPSTF recommendations had a grade B recommendation to screen women aged 50-74 years. For women aged 40-49, the prior recommendation was for an individualized decision which included considerations of how women valued potential benefits and harms (grade C). (USPSTF 2016, archived)
• Evidence for initiating screening at age 40: Outcomes of six Cancer Intervention and Surveillance Modeling Network (CISNET) models estimated that initiating biennial screening at age 40 (as opposed to age 50) would avert an additional 1.3 breast cancer deaths, with an additional 503 false-positive recalls, 65 benign biopsies, and 2 overdiagnosed breast cancer cases per 1000 women screened. For Black women, models beginning at age 40 (compared to 50) resulted in 1.8 additional breast cancer deaths averted (Trentham-Dietz, 2024). Furthermore, epidemiological data shows the invasive breast cancer incidence in young women  is increasing, for women 40-49 at an average of 2% annually between 2016 and 2019 (SEER database, Xu 2024). Dr. Nicholson emphasizes the benefits far outweigh potential harms, and she notes that from a population level the earlier age of screening initiation corresponds to up to 25,000 women’s lives saved.
• Screening interval: The USPSTF continues to recommend biennial screening mammography, given evidence suggesting that it has a more favorable balance of benefits vs harms as compared to annual screening (Trentham-Dietz, 2024). Data from the Breast Cancer Surveillance Consortium (BCSC), a large observations database including 6 active breast imaging registries and 2 historic registries, did not show a difference in detecting cancers (stage IIB or higher and with unfavorable prognosis) (Miglioretti, 2015).
• Patient population: This recommendation applies to women at average risk for breast cancer aged 40 to 74, with clear and inclusive language that this applies to all persons assigned female at birth (including cisgender women, transgender men, and non-binary individuals). This recommendation applies to women with a family history of breast cancer and those with dense breasts.
• Exclusions: The recommendation does not apply to high-risk individuals, such as those with a personal history of breast cancer, high-risk gene mutations, or exposure to high-dose chest radiation at a young age. Of note, women with concerning family histories including risk of BRCA1/2 should be assessed with a brief assessment tool for potential genetic counseling (USPSTF, 2019).

For women 75 years and older, the USPSTF concludes evidence is insufficient to assess the balance of benefits and harms of screening mammography (grade I).

• This recommendation remains unchanged from prior.
• A large, random sample of Medicare claims data did not suggest any mortality benefit with continued screening beyond age 75 years. On the other hand, comparing the value of stopping screening at age 79 versus age 74, the collaborative modeling study found a small benefit of an additional 1 breast cancer death averted and 67-172 more false positive cases per thousand women (Trentham-Dietz, 2024). Further research is required.

For women with dense breasts with an otherwise negative screening mammogram, the USPSTF concludes current evidence is insufficient to assess the balance of benefits and harms of supplemental screening using breast ultrasonography or MRI (grade I).

• This recommendation remains unchanged from prior.
• Up to half of women in the US have dense breasts, and dense breasts are associated with less effective mammography and increased risk of breast cancer (Price, 2013).
•  There is not clear evidence of the impact of supplemental screening on outcomes (eg morbidity, mortality). Further research on the benefits and harms is a priority, for example evaluating advanced breast cancer diagnosis and patient-centered health outcomes.

Understanding and Addressing Disparities

• Despite similar screening rates, mortality rates from breast cancer is approximately 40% higher in Black women compared to their White counterparts (CDC and SEER databases, Richardson 2016)
• The reasons for this disparity are complex and not fully understood, and may include healthcare system factors, environmental exposures, and genetic differences. Epidemiological data shows Black women are more likely to be diagnosed with an advanced cancer or with worse prognostic biomarkers(SEER database).
• Inequities should be examined at each step in the process, and clinicians should ensure all eligible women are offered breast cancer screening and those with abnormal results receive equitable and appropriate follow-up.
•  Further research is required around the higher mortality in Black women, including reasons why they are more likely to be diagnosed with cancers with poor-prognosis biomarker patterns, understanding variations in care and how to reduce disparities, and the balance of benefits and harm or annual screening.

Links

• USPSTF Recommendation Statement on Breast Cancer Screening, April 2024

Goal

The goal of this episode is to understand the reasoning behind USPSTF breast cancer screening recommendations to change the age to start screening for all women to 40 years of age.

Learning objectives

1. Review the updated USPSTF recommendations for breast cancer screening
2. Understand the reasoning behind the recommendations change.

Disclosures

Dr. Nicholson has no financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Syed F, Nicholson W,  Williams PN, Watto MF. “USPSTF Breast Cancer Screenings.” The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast 10 July 2024