All Women Should Get Mammograms at Age 40
By Tammy McCausland
This blog post is adapted from the article “Mammograms for All Women at Age 40” published in Vol. 33 No. 4 of Radiation Oncology for Administrators.
A survey by the Ohio State University Comprehensive Cancer Center suggests nearly one-third of women are confused about breast cancer screening recommendations. This finding is concerning, especially since in May 2023 the United States Preventive Services Task Force (USPSTF) issued a practice-changing draft recommendation on screening for breast cancer: it recommends all women should get screened starting at age 40.
“The task force is saying that all women should start getting screened every other year at age 40 to help them live longer and healthier lives,” says John Wong, MD, vice chair for Academic Affairs and a primary care clinician in the Department of Medicine at Tufts Medical Center. “We based that change on new and more inclusive science that shows that women in their 40s will now benefit more from screening.” The data, which come the National Cancer Institute’s SEER database, are now more representative of the demographics the U.S. population than before when the data were largely based on Caucasian women.
“The new draft recommendation is a positive step forward in the sense that many of the medical societies have long recommended starting screening at age 40,” says Bruce Haffty, MD, chair of Radiation Oncology at Rutgers Cancer Institute of New Jersey. “The data suggest it makes sense to start screening sooner, particularly for African-American and Asian women who tend to have a younger age onset of breast cancer.”
Previously USPSTF recommended that women could choose to start breast cancer screening between ages 40 and 50. “What probably weighed the most in our thoughts was that the evidence shows that more women in their 40s are developing breast cancer every year—2 percent more every year since 2015,” Dr. Wong says. “We used modeling analysis and found that by starting screening at age 40, we have the potential to save about 20 percent more lives among women screened and that Black women may have even greater benefit.”
While increasingly women are diagnosed with breast cancer between ages 40 and 50, Dr. Haffty says researchers cannot definitively say why from an epidemiological perspective. A 2021 study published in the journal Cancer, found that compared to Non-Hispanic White women, minority women were “72% more likely to be diagnosed under the age of 50 years. . . 58% more likely to be diagnosed with advanced-stage breast cancer under the age of 50 years . . . and 24% more likely to be diagnosed with advanced-stage (regional or distant) breast cancer at all ages.” The study also found that “Among women dying of breast cancer, minority women were 127% more likely to die under the age of 50 years than NH-White women.”
Screening usually results in earlier detection, even at a stage of being noninvasive, which has an almost 100 percent cure rate, or small, early-stage, node-negative breast cancers, which have cure rates in excess of 90 percent, explains Dr. Haffty. “Finding breast cancer earlier on a screening mammogram as opposed to when women feel something or have a symptom, generally means it’s detected at an earlier, more curable stage,” he says. When breast cancer is caught at an early stage, patients may be able to avoid systemic chemotherapy, or they may be able to opt for a lumpectomy rather than a mastectomy because the tumor is smaller.
“Quality of life is extended by screening because you are potentially avoiding the consequences of diagnosing breast cancer at later stages when it may have spread to other parts of the body,” says Dr. Wong. Later-stage cancer diagnoses are always harder to treat, and life expectancy is also reduced.
More research is needed regarding how to best address health disparities that minority women face (Black, Latina, Asian, Native American and Alaska Native); how to ensure equitable follow-up after screening; the benefits and harms of screening and treatment of women age 75 and older; and whether women with dense breasts require additional screening.
Breast density is another issue. Nearly 50 percent of women have dense breasts and mammograms don’t work as well for them. There are groups advocating for women with dense breasts to get additional screening through ultrasound or MRIs. In March 2023, the U.S. Food & Drug Administration updated its mammography regulations “to require mammography facilities to notify patients about the density of their breasts.” But there isn’t yet sufficient scientific evidence for the task force to make recommendations about additional screening for women with dense breasts.
Dr. Wong says radiation oncology administrators can help deliver the message that screening saves lives through their patient education and other initiatives. “Administrators understand the importance of preventive screening very well because their cancer centers deliver radiation therapy to women who have breast cancer,” he says.
Cancer centers that serve underrepresented communities can increase public awareness by having screening literature readily available and accessible to patients.
While the USPSTF recommends screening every other year, Dr. Haffty suggests yearly screening may be better. “I would advocate for yearly. Some of the medical societies advocate for yearly mammograms. In terms of practicality, I think it can fall off the patient’s radar and every other year could turn into several years where people forget about getting screened,” he says.
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