In Reversal, Expert Panel Recommends Breast Cancer Screening at 40

Citing rising breast cancer rates among young women, a panel of experts on Tuesday recommended starting regular mammogram screening at age 40, overturning a long-standing and controversial recommendation that most women wait up to 50 years old.

The panel, the U.S. Preventive Services Task Force, finalized a draft recommendation made public last year. The group publishes influential advice on preventive health, and its recommendations are generally widely adopted in the United States.

In 2009, the task force increased the age to begin routine mammograms from 40 to 50, sparking widespread controversy. At the time, researchers worried that earlier screening would do more harm than good, leading to unnecessary treatments in younger women, including alarming results that lead to anxiety-inducing, invasive but ultimately unnecessary procedures.

But today, breast cancer rates among women in their 40s are on the rise, increasing 2% annually between 2015 and 2019, said Dr. John Wong, vice chair of the task force. The panel continues to recommend screening every two years for women at average risk for breast cancer, although many patients and providers prefer annual screening.

“There is clear evidence that starting screening every two years at age 40 provides enough benefit that we should recommend it to all women in this country to help them live longer and to have a better quality of life,” said primary care specialist Dr. Wong. clinician at Tufts Medical Center and director of comparative effectiveness research for the Tufts Clinical Translational Science Institute.

The recommendations have faced 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 does not not far enough.

In a letter to the task force in June, they said the guidance continued to “fall short of scientific evidence, create coverage gaps, generate uncertainty for women and their providers, and exacerbate health disparities.

Speaking again on a highly controversial topic, the task force also said there was not enough evidence to endorse additional tests, such as ultrasounds or magnetic resonance imaging, for women with dense breast tissue.

This means that insurers are not required to provide comprehensive additional screening coverage to these women, whose cancers may not be detected by mammograms alone and who are at higher risk of breast cancer. About half of all women aged 40 and over fall into this category.

In recent years, more and more mammographers have been required by law to notify women when they have dense breast tissue and to tell them that mammography may be an insufficient screening tool for them.

Starting in September, all mammography centers in the United States will be required to provide this information to patients.

Doctors often order additional or “complementary” tests for these patients. But these patients often find themselves having to pay all or part of the costs themselves, even when the additional tests are carried out as part of preventive care which, by law, should be offered free of charge.

Medicare, the government health plan for older Americans, does not cover additional testing. In the private insurance market, coverage is scattered, depending on state laws, plan type, and plan design, among other factors.

The task force sets standards for preventive care services that must be covered by law by health insurers, at no cost to patients.

The panel’s decision not to approve additional testing has significant implications for patients, said Robert Traynham, a spokesman for AHIP, the association that represents health insurance companies.

“What that means in terms of coverage is that there is no mandate to cover these specific screenings for women with dense breasts with zero cost sharing,” he said.

Although some employers may choose to have their health insurance plans do so, the law does not require it, Mr. Traynham said.

Kathleen Costello, a Southern California retiree who was diagnosed with breast cancer in 2017 when she was 59, said she was convinced mammograms had not detected her cancer for many years .

She was screened every year and received a letter every year informing her that she no longer had cancer. The letters also told her that she had dense breast tissue and that additional screening was available but not covered by insurance.

Six months after a mammogram in 2016, she told her doctor that her right breast was stiff. The doctor ordered a mammogram and ultrasound.

“Within 30 seconds, the ultrasound detected the cancer,” Ms. Costello said in an interview, adding that she knew because “the technician blanched and left the room.”

The mass measured four centimeters, Ms Costello added: “It’s difficult for me to accept that it had gone from undetectable to four centimeters in six months.”

But the task force’s Dr Wong said there was no scientific evidence to prove that additional imaging, through MRI or ultrasound, reduced the progression of breast cancer and prolonged the lives of women with tissue dense breast.

In contrast, there is ample evidence that additional screenings can lead to frequent false-positive results and biopsies, thereby contributing to stress and unnecessary invasive procedures.

“It’s tragic,” Dr Wong said. “We are as frustrated as the women. They deserve to know whether additional screenings would be helpful.

But medical organizations like the American College of Radiology recommend additional screening for women with dense breast tissue. Research shows that ultrasound combined with mammography detects additional cancers in patients with dense tissue, said Dr. Stamatia Destounis, chair of the college’s breast imaging committee.

For women with dense breasts who are at average risk for breast cancer, recent research indicates that MRI is the best complementary test, Dr. Destounis said, “with much better cancer detection and higher positive predictive values.” favorable”.

The college also recommends annual screening for women at average risk for cancer, rather than every two years as the committee recommends. The radiologists’ group is pushing for a recommendation that all women be assessed for breast cancer risk before the age of 25, so that high-risk women can begin screening even before they are 40 years.

Growing evidence shows that black, Jewish and other minority women develop and die from breast cancer before age 50 more frequently than other women, Dr. Destounis noted.

Trans men who haven’t had a mastectomy should continue to be screened for breast cancer, she added, and trans women, whose hormone use puts them at higher risk for breast cancer. breast than the average man, should discuss screening with their doctor.

Although the committee’s advice to begin screening at age 40 is “an improvement,” Dr. Destounis said, the final recommendations “do not go far enough to save women’s lives.”

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