Citing rising breast cancer rates in young women, an expert panel on Tuesday recommended starting routine mammography screening at age 40, reversing a longstanding and controversial guideline that most women wait until age 50.
The US Preventive Services Task Force finalized a draft recommendation that was made public last year. The group publishes influential advice on preventive health, and its recommendations are generally widely accepted in the United States.
In 2009, the task force raised the age for starting routine mammograms from 40 to 50, sparking widespread controversy. At the time, researchers worried that earlier screening could do more harm than good, leading to unnecessary treatment for young women, including potentially dangerous findings that could lead to invasive but ultimately unnecessary anxiety-producing procedures.
But now the rate of breast cancer among women in their 40s is rising, increasing by 2 percent a year between 2015 and 2019, said Dr. John Wong, vice chair of the task force. Although many patients and providers prefer annual screening, the panel continues to recommend screening every two years for women at average risk of breast cancer.
“There is clear evidence that starting screening every year at age 40 is beneficial enough that we should be recommending it to all women in this country to help them live longer and have a better quality of life,” Dr Wong said. The doctor at Tufts Medical Center is director of comparative effectiveness research at the Tufts Clinical Translational Science Institute.
The recommendations have drawn sharp criticism from some women's health advocates, including Rep. Rosa DeLauro, Democrat of Connecticut, and Rep. Debbie Wasserman Schultz, Democrat of Florida, who say the advice is inadequate.
In A letter to the Working Group in JuneThey said the guidance continues to “lack science, create coverage gaps, create uncertainty for women and their providers, and exacerbate health disparities.”
Weighing back in on the hotly debated topic, the task force said there was insufficient evidence to endorse additional scans, such as ultrasound or magnetic resonance imaging, for women with dense breast tissue.
That means cancers can be avoided with mammograms alone and insurers don't have to offer full coverage of additional screening for women at high risk of developing breast cancer. Half of all women aged 40 and over fall into this category.
In recent years, more mammography providers have been required by law to inform women when their breast tissue is dense and tell them that mammography may be an adequate screening tool for them.
Starting in September, all mammography centers in the U.S. must provide that information to patients.
Doctors often recommend additional or “supplementary” scans for these patients. But these patients may have to pay all or some of the costs themselves, even if the extra tests are done as part of preventive care that should be provided at no cost under the law.
Medicare, the government health plan for older Americans, does not cover additional scans. In the private insurance market, coverage is dispersed depending on other factors such as state laws, type of plan, and plan design.
The task force sets standards for health insurers to provide preventive care services at no cost to patients under the Act.
The panel's decision not to authorize additional scans has significant implications for patients, said Robert Tranham, a spokesman for AHIP, the association that represents health insurance companies.
“What that means for coverage is that there is no mandate to share these specific screenings at zero dollar cost to women with dense breasts,” she said.
While some employers choose to do so with their health insurance plans, Mr. Tryndham said.
Southern California retiree Kathleen Costello, who was diagnosed with breast cancer in 2017 at age 59, said she believes mammograms have missed her cancer for years.
She underwent annual screenings and received a letter each year saying she was cancer-free. The letters said she had dense breast tissue and had additional screening, but was not covered by insurance.
Six months after having an all-clear mammogram in 2016, she told her doctor that her right breast was hard. The doctor ordered a mammogram and ultrasound.
“Within 30 seconds, the ultrasound found cancer,” Ms. Costello said in an interview, adding that she only knew because “the technician left the room.”
The mass was four centimeters in size and Mrs Costello added: “It's hard for me to accept that it has grown from undetectable to four centimeters in six months.”
But Dr. of the task force. Wong said there is no scientific evidence to prove that adjunctive imaging with MRI or ultrasound slows the growth of breast cancer and prolongs life in women with dense breast tissue.
On the other hand, there is ample evidence that ancillary screenings often lead to false-positive findings and biopsies, contributing to stress and unnecessary invasive procedures.
“It's tragic,” Dr. Wong said. “Like women, we are desperate. They deserve to know if additional screenings can help.”
But medical organizations such as the American College of Radiology support additional screening for women with dense breast tissue. Research shows that ultrasound combined with mammography can detect additional cancers in patients with dense tissue, said Dr. Stamatia Testonis, chair of the college's breast imaging commission.
Recent research indicates that MRI is the best adjunctive scan for women with dense breasts who are at average risk of breast cancer, Dr. Testonis said, “with very good cancer detection and favorable positive predictive values.”
The college recommends annual screening for women at average cancer risk rather than screening every two years as recommended by the panel. The panel of radiologists is stressing the recommendation that all women be assessed for breast cancer risk before age 25, so that women at high risk can begin screening before age 40.
Growing evidence shows that black, Jewish and other minority women develop breast cancer and die before age 50, Dr. Testonis noted.
Men who have not had a mastectomy should continue to be screened for breast cancer, and trans women should discuss screening with their doctor if they use hormones that put them at a higher risk for breast cancer than the average man.
While the panel's recommendation to start screening at age 40 was “a step forward,” the final recommendations “didn't go far enough to save women's lives,” Dr. Testounis said.
