Oops, they did it again — that is, the U.S. Preventive Services Task Force once more changed their screening recommendations for breast cancer.
In 2016, the USPSTF recommended breast cancer screening start at age 50 and continue every other year until age 74. They also recommended anyone in their 40s who wanted screening to discuss risk with their doctor.
New guidelines, published Tuesday in JAMA, now recommend breast cancer screening start at age 40 and continue every other year until age 74 to better serve younger women. The latest data, which span 2015 to 2019, show a 2% increase in breast cancer diagnoses per year among women in their 40s.
Janie Lee, MD, MSc, Fred Hutch Cancer Center’s director of breast imaging, said the recommendations align with those of both Fred Hutch and UW Medicine.
“We have joint breast cancer screening guidelines across both organizations and across departments — primary care, radiology and breast oncology,” she said. “The consensus recommendation endorses beginning screening at age 40.”
Lee, who acknowledged the havoc often caused by changing guidelines, said she was optimistic about these recommendations, mainly because they “better align with other groups that issue breast cancer screening guidelines.”
“With more clear consensus across guidelines, I hope there will be less confusion among women about breast cancer screening,” she said. “The scientific evidence is clear that mammography saves lives.”
Cancer screening guidelines are issued by several large national organizations: the USPSTF and the American Cancer Society are the most well-known. But other groups, like the American College of Radiology, the Society of Breast Imaging, and National Comprehensive Cancer Network, or NCCN, also regularly issue, and update, cancer screening guidelines.
Unfortunately, these guidelines don’t always agree.
Case in point: the American Cancer Society’s guidelines for breast cancer screening recommend yearly mammograms from age 45 until menopause, then they're every other year. Read the full ACS breast screening guidelines here. Previous ACS guidelines recommended annual mammograms starting at age 40.
This latest update means most of the organizations are now on the same page. The American College of Radiology, the Society of Breast Imaging, the American College of Obstetricians and Gynecologists and the NCCN all recommend mammography screening start at age 40 for women at average risk.
Why do they flip back and forth all the time? Lee said it’s because new information continues to roll in from ongoing studies and clinical trials.
“Since the USPSTF guidelines were last issued in 2016, new trials have reported results,” she said. “There has been more specific evaluation of digital breast tomosynthesis, also known as 3D mammography. Guidelines change in part because information changes.”
As for the differing opinions, each organization has their own focus, according to Fred Hutch biostatistician Ruth Etzioni, PhD, who’s served on various guidelines committees. Etzioni is the holder of the Rosalie and Harold Rea Brown Endowed Chair.
“The USPSTF is predominantly made up of primary care doctors and, thus, is concerned with the whole, healthy population,” she said. “The American Cancer Society is all about reducing death from cancer, so their guidelines have traditionally been more rigorous.”
— Fred Hutch's Dr. Janie Lee, director of imaging
Interested in breast cancer screening? First talk to your primary care provider to determine your risk for the disease.
Don’t have a PCP? If you have insurance, you can search their provider database for one in your network. You can also ask family and friends who they recommend or look online for PCP reviews. Information about UW Medicine primary care providers can be found here. Or use these additional tips for finding a PCP.
If you’re in the Pacific Northwest region, Fred Hutch and UW Medicine have several mammogram sites including Fred Hutch – South Lake Union, where results are shared right away.
“In and out” screening can also be done at UW Medicine sites at UW Medical Center -Northwest, Roosevelt Clinic and the Eastside Specialty Clinic.
The Fred Hutch mobile mammography van also provides screening where women live and work. A photo tour of the mobile van can be found here.
Wait times for specific locations run a few weeks at present, per Fred Hutch’s Janie Lee, MD, MSc, but “if you have flexibility on where you might have your mammogram, the wait time will be shorter.”
You can also self-schedule a mammogram via MyChart.
One important distinction is that USPSTF guidelines are the basis for decisions regarding insurance coverage, thanks to the Affordable Care Act, which requires health insurers to fully cover task force recommendations that receive a rating of Grade B or higher.
Once the USPSTF recommends a procedure, the Centers for Medicare & Medicaid Services, or CMS — public insurance — will pay for it. And once CMS covers it, commercial or private insurers usually follow suit. That means people aged 40 to 74 should have no trouble getting screening mammograms covered by their insurance, whether public or private.
Screening mammography is designed for those who have no symptoms of breast cancer. It’s a way to find these cancers early.
“Finding cancers earlier provides patients with more, and often less-aggressive, treatment options,” Lee said. “Screening mammograms typically includes two images of each breast.”
Diagnostic mammograms are a little different. They’re designed for those who have been asked to return for additional imaging after a screening mammogram, or for women who have symptoms such as a breast lump/change or nipple discharge.
“Diagnostic imaging includes special views focused on the area of concern and may also include breast ultrasound,” Lee said.
Costs for mammography — and other screening procedures — vary.
Most insurance companies consider a screening mammogram a medically necessary preventive service, according to Rowena Fish, who works in Fred Hutch’s patient finance department. This means annual mammograms should be covered with no out-of-pocket cost.
“Insurance coverage for additional imaging and tests such as diagnostic mammograms, ultrasounds, breast MRIs and biopsies varies depending on the state and insurance company,” she said. “You should check with your insurance carrier to learn if and how these services are covered.”
In addition, Lee pointed to a new Washington state law that prohibits co-pays for diagnostic breast imaging and supplemental screening for women at increased risk of breast cancer.
“This is great news for patients,” she said. “It’s removing an important barrier for breast cancer diagnosis, although there are some exemptions so it doesn’t apply to all patients. We’re currently working on developing communication materials to help our patients understand this new law.”
Fish said Fred Hutch also works with uninsured and underinsured patients to determine if they qualify for one of the several assistance programs or grants that are available for these services. There’s also a patient-friendly tool to look up pricing information for various services.
In addition to lowering the age for screening, the USPSTF also concluded they didn’t have enough evidence to make a recommendation for those age 75 and older; it’s basically choose-your-own-screening-adventure.
The group also issued no specific recommendations for those with dense breasts, stating “the current evidence is insufficient to assess the balance of benefits and harms of supplemental screening using [ultrasound or MRI].”
Lee said dense breast tissue can be a risk factor for breast cancer, however, “having dense breasts does not mean that a woman is automatically at high risk of developing it.”
“Understanding individual breast cancer risk includes considering other factors such as family history, prior breast biopsies and other clinical factors,” she said. “We encourage women to consult with clinicians who focus on women’s health. They can provide a more in-depth breast cancer risk assessment.”
While USPSTF guidelines are designed for women at average risk, she said those at high risk might be eligible for “supplemental screening with breast MRI.”
“We know that breast density is a risk factor for breast cancer, and that clinical trials are evaluating how best to use imaging to improve early detection and save more lives,” she said. “The USPSTF and other guideline groups have rigorous processes to assess the evidence and update recommendations. While the evidence is not yet strong enough to endorse supplemental screening for all women with dense breasts, additional clinical trials are underway.” Read a related JAMA editorial, Toward More Equitable Breast Cancer Outcomes, co-authored by Fred Hutch's Christoph Lee, MD, MS, MBA.
Unfortunately, clinical trials take time — to design, to conduct and to report results back to the scientific community which then uses that information to finesse screening guidelines.
“It also takes additional time to establish updated insurance coverage policies,” Lee said. “As a scientific community, beyond conducting new studies, we also need to be working to shorten the lag between closing knowledge gaps and improving clinical care.”
Approximately 43,000 people died of metastatic or advanced breast cancer in 2023; the majority of cases occur between ages 55 and 74 years of age.
Etzioni, who researches the risk vs. benefit of preventive cancer screening, expressed concern about the accuracy of mammography in the new subset of younger women, since women in their 40s tend to have denser breast tissue and dense breast tissue tends to “hide” breast cancer.
“Having dense breasts increases the biological risk — which has been confirmed by our research — but it also makes it harder to see the cancer,” she said, explaining that both dense tissue and breast cancer appear white on mammograms. It's a bit like trying to spot a polar bear in a blizzard.
“If women in their 40s are to be screened, it’s critical to recognize that mammogram performance in this age group is not as good as in older women,” she said. “The Task Force recommendation is a guide. It's important for women to know their breast density and to know what it means. Women with dense breasts may want to consider more frequent screening than every other year.”
The ACS states that 3D mammograms (also known as breast tomosynthesis) “might be particularly helpful” for those with dense breasts. ACS also recommends those at higher risk (based on inherited gene mutations, a strong family history of breast cancer or other factors), have an MRI along with a yearly mammogram.
Black patients, who are 40% more likely to die from breast cancer than white women, may benefit the most from the new guidelines.
“Black women often have aggressive cancers at younger ages,” Lee said. “The new guidelines supporting eligible women, and especially Black women, to start screening at age 40 are important to better communicate the benefits of mammography for reducing breast cancer deaths.”
Breast cancer is the second leading cause of cancer mortality in U.S. women, but it’s the number one cause of death in Black and Hispanic women despite a steady decline in overall mortality rates over the past two decades.
Black women have a lower five-year survival rate, no matter the breast cancer subtype — or the stage — of the disease.
According to ACS Cancer Surveillance’s senior scientific director Rebecca Siegel, MPH, this points to discrepancies in care, rather than overly aggressive biological subtypes.
“We have been reporting this same disparity year after year for a decade,” she said in a recent news release. “The differences in death rates are not explained by Black women having more aggressive cancers. It is time for health systems to take a hard look at how they are caring differently for Black women.”
Etzioni said when it comes to screening guidelines, it's all about finding the right balance.
“The Task Force does a very careful job of weighing benefits and harms and they truly try to recommend what they feel is the best balance,” she said.
“But what is not included in the calculation of benefit and harm is the benefit of having concurrent guidelines with other major national groups like the American Cancer Society versus the harms of having discordant guidelines.”
Diane Mapes is a staff writer at Fred Hutchinson Cancer Center. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor, she blogs at doublewhammied.com and tweets @double_whammied. Email her at dmapes@fredhutch.org. Just diagnosed and need information and resources? Visit our Patient Care page.
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Are you interested in reprinting or republishing this story? Be our guest! We want to help connect people with the information they need. We just ask that you link back to the original article, preserve the author’s byline and refrain from making edits that alter the original context. Questions? Email us at communications@fredhutch.org
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