News | Breast Imaging | May 01, 2024

Leading Organizations and Breast Imaging Experts Weigh in on New Task Force Screening Recommendations, Impact on Health Equity and Women’s Health

After the issuance of updated recommendations for breast cancer screening by the U.S. Preventive Services Task Force (USPSTF) on April 29, a number of leading imaging specialists have offered their replies. Here, then, are summaries of statements issued in response. Imaging Technology News/ITN will continue to monitor and report on this important issue.

After the issuance of updated recommendations for breast cancer screening by the U.S. Preventive Services Task Force (USPSTF) on April 29, a number of leading imaging specialists have offered their replies. Here, then, are summaries of statements issued in response. Image courtesy: Getty Images

May 1, 2024 — After the issuance of updated breast screening recommendations by the U.S. Preventive Services Task Force (USPSTF) on April 29, a number of leading imaging specialists have offered their replies. Here, then, are summaries of statements issued in response.

From the American Cancer Society (ACS)

The American Cancer Society (ACS) commended the updated recommendations for breast cancer screening from the United States Preventive Services Task Force (USPSTF) for lowering the age to begin mammography screening to age 40, noting they are more consistent with ACS guidelines. The organization, in its statement, noted that breast cancer is the second most common cancer and the second most common cause of cancer death for women in the United States, adding that mammography continues to be the best screening tool to detect breast cancer and save lives. The statement follows:

“The USPSTF decision today is a critical change concerning women’s health and the fight against breast cancer, acknowledging that women in their 40s will benefit from mammography screening, and sending a strong message to referring physicians and women that breast cancer screening should begin earlier than age 50. ACS guidelines already call for women at average risk to have the opportunity to begin annual breast cancer screening at age 40, with regular screening beginning for all women at age 45. Mammography screening is the cornerstone of our strategy to find this potentially deadly disease early, when it’s easier to treat successfully. However, we are disappointed that the updated USPSTF screening recommendations do not include women over the age of 74. Millions of women over age 75 are in very good health and are expected to live many more years during which their risk of breast cancer remains high. The ACS does not support stopping screening for anyone with a 10+ year life expectancy irrespective of age.”

“We are encouraged that among the reasons for the USPSTF changes in their breast cancer screening recommendations include eliminating health disparities, especially among Black women, who are 40% more likely to die of breast cancer compared with White women and have a higher risk of aggressive breast cancers at all ages. This is an important step, but much more needs to be done to protect this vulnerable population of women. We also join with the USPSTF in their urgent call for further research in this area to help make informative decisions to protect women from breast cancer.”

From Dana-Farber Cancer Institute, a principal teaching affiliate of Harvard Medical School

Below is a statement attributable to Ann Partridge, MD, MPH, Director of the Program for Young Adults with Breast Cancer at Dana-Farber Cancer Institute, which is part of Harvard University.

“It is a welcome change that the U.S. Preventive Services Task Force guidelines now support routine mammography screening for women beginning at age 40, given the increasing rates of breast cancer in younger women. While these updated guidelines are a positive development, there are, however, concerns that the every-other-year screening recommendation may lead to even less screening among some populations, and result in more cancers ultimately being detected at advanced stages. Therefore, it would be prudent to support patients and doctors, including radiologists reviewing the imaging, to make tailored decisions regarding frequency of screening for breast cancer, with the option of screening annually.”

From UCLA Health

While the recommendations offer a step forward in making screening equitable for populations that have been missed with the previously higher screening starting age, challenges remain in ensuring equitable access to screening and addressing gaps in evidence regarding supplemental screening modalities and the adoption of artificial intelligence (AI) technologies, notes Joann Elmore, MD, MPH, a professor of medicine at the David Geffen School of Medicine at UCLA in a newly published editorial, "Toward More Equitable Breast Cancer Outcomes," in JAMA.

Authored by Elmore, a member of the UCLA Health Jonsson Comprehensive Cancer Center, and Christoph Lee, MD, MS, University of Washington School of Medicine, the editorial discusses the key updates in the recommendations, which along with addressing health inequities include the incorporation of new screening technology.

The recommendations now include digital breast tomosynthesis, also known as 3D mammography, as a primary screening modality. Digital breast tomosynthesis has shown promise in improving the benefit-to-risk ratio compared to traditional digital mammography, primarily by reducing false-positive results. However, there are many challenges in implementation of these technologies, the authors noted.

“Encouraging earlier screening starting at age 40 years represents just one facet of the breast care continuum. These assumptions include women accessing screening facilities with up-to-date technology, receiving prompt diagnostic evaluations, and accessing high-quality definitive treatment — a reality that does not always hold, particularly for individuals belonging to groups and communities that are traditionally underserved and under resourced,” they wrote.

Studies have revealed inequalities in access to 3D mammography facilities and delays in obtaining diagnostic evaluations, which undermine the benefits of early cancer detection.

There’s also a need for more research on supplemental screening modalities, such as ultrasound or MRI, for women with dense breasts. Nearly half of all women in the United States have dense breasts, and this is a normal variation associated with a small increase in breast cancer risk similar to having an aunt with breast cancer, yet there is currently inadequate evidence to recommend for or against additional screening for this population.

This is especially urgent, the authors write, since the Food and Drug Administration (FDA) will start mandating that all US screening facilitates will need to inform women about their breast density with their mammography results starting in September of 2024.

The authors also raise concerns about the emerging use of Artificial Intelligence (AI) support tools for image interpretation in mammography. While AI algorithms show promise in enhancing cancer detection, their impact on patient outcomes remain uncertain.

Additionally, these AI tools have been primarily trained on white women, potentially exacerbating existing disparities, said Elmore and Lee. These tools need to be validated on diverse populations to ensure benefits are equitable across all races and ethnicities.

“There are still many pressing issues that are overlooked and understudied in breast cancer screening, such as the impact of AI as a tool to support radiologists,” said Elmore. “Moving forward, it is crucial that physicians continue to practice the art of medicine, talking with women about the potential benefits and harms of screening and supporting women as they make informed decisions that align with their own preferences.”

From DenseBreast-info.org

The U.S. Preventive Services Task Force (USPSTF) released updated recommendations for breast cancer screening (April 30) in JAMA. In a companion editorial in JAMA Oncology, “USPSTF Breast Cancer Screening Guidelines Do Not Go Far Enough,” Wendie Berg, MD, PhD, FACR, Professor of Radiology at University of Pittsburgh School of Medicine and Chief Scientific Advisor for DenseBreast-info.org (DBI), commends the USPSTF for expanding potential benefits of screening mammography to start at age 40 but expresses concern about inadequate screening for women with dense breasts.

In the editorial, Berg focused on key advances and opportunities to enhance breast cancer screening guidelines moving forward, including:

· Annual vs Biennial: While an important step that USPSTF now supports regular screening beginning at age 40, it is surprising that the recommendations call for biennial mammography, which carries a smaller breast cancer mortality reduction (28.4%) vs annual mammography (35.2%).

· Dense Breast Screening: The USPSTF states that evidence is insufficient to support supplemental screening beyond mammography in women with dense breasts, but they ignored key evidence. Supplemental screening with MRI especially has proven benefits and is recognized by the American College of Radiology (ACR) and European Society of Breast Imaging (EUSOBI). In women who cannot have MRI, ultrasound can be considered.

· High Risk: The USPSTF guidelines do not apply to women at high risk of breast cancer. Many women with dense breasts and personal/family history are at high risk. ACR and EUSOBI endorse risk assessment at age 25 to identify women who may benefit from early initiation of screening MRI.

“The updated USPSTF updated recommendations are an important step forward, but they stop short. Research shows that not only is annual mammography as efficient as biennial, but it also delivers greater overall gains in years of life saved. We encourage USPSTF to consider annual screening and the commencement of regular risk assessment at age 25 to identify women at high risk due to family history or breast density who should consider supplemental screening, including MRI, or breast ultrasound if MRI is not possible,” said Berg.

As of September 10, 2024, the new FDA standard requires all women in the U.S. to be notified if they have dense breasts or not in their mammogram results letters.

“For women to benefit from appropriate screening, they must participate and have a discussion with their medical provider about their breast density and other risk factors. DBI continues to focus on providing comprehensive education to support such conversations. Adequate breast cancer screening should be available to all women, and this will require passage of the Find It Early Act to assure a national standard for insurance coverage,” said JoAnn Pushkin, Executive Director, DBI. DBI is the world’s leading medically-sourced website on the topic, featuring educational tools for patients and health providers which has grown from 40,000 visits in 2016 to an estimated one million in 2024.

More information: www.uspreventiveservicestaskforce.org, www.cancer.org, www.dana-farber.org, www.uclahealth.org, www.DenseBreast-info.org