In an effort to improve early detection of breast cancer and address disparities in outcomes, the US Preventive Services Task Force (USPSTF) has issued updated breast cancer screening recommendations to now advise all women to undergo routine screening every other year starting at age 40 —representing a significant shift from previous guidelines, which recommended screening starting at age 50 and engaging in individualized decision-making for women aged 40 to 49.
The revised guidelines aim to enhance early detection of breast cancer and tackle disparities in breast cancer mortality, particularly among Black women, who are more likely to have aggressive cancer subtypes diagnosed at later stages and face disproportionately higher mortality rates: 40% higher compared to white women in the United States.
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 in JAMA.
Authored by Dr. Elmore, who is also a member of the UCLA Health Jonsson Comprehensive Cancer Center, and Christopher Lee, MD, MS, from the 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 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 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 Dr. Elmore and Dr. 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 Dr. 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."
