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Breast cancer screening should start at 40, new expert recommendations say

In their latest recommendations, the U.S. Preventive Services Task Force says mammograms should start earlier.
/ Source: TODAY

Screening for breast cancer should now start earlier, a major expert group says. People with breasts should now get a mammogram every other year starting at age 40 — not 50, the United States Preventive Services Task Force recommends.

Since 2009, the USPSTF recommended that women with an average risk for breast cancer should start getting screened at age 50.

The independent expert panel updated its recommendations in 2016 to include a provision that women could start getting mammograms at age 40 if they wanted to. But the decision needed to be individualized and balanced with the risks of potential false-positives.

Now, the group has made an even bigger change.

The new guidelines, which are largely similar to a draft recommendation released last year, can help detect more breast cancers at earlier stages. And that will have a particularly major impact on Black women who are more likely to develop aggressive cancers at younger ages than white women, the panel says.

However, other experts say the new guidelines still don't go far enough in detecting aggressive breast cancers in younger people.

What are the new USPSTF breast cancer screening guidelines?

Here are the new breast cancer screening guidelines from the USPSTF:

  • Women with an average risk for breast cancer should have mammograms, a type of X-ray, every other year from ages 40 through 74.
  • People with a higher-than-average risk for breast cancer, such as a family history or genetic factors, should talk to their doctor about when to start screening.

The new recommendations also highlight a few areas in which more research is sorely needed, Dr. Wanda Nicholson, chair of the task force and professor of prevention and community health at the Milken Institute School of Public Health at the George Washington University, tells

There's still not enough data to recommend for or against continued screening at age 75 and above, for example. Additionally, there's not enough evidence to weigh the potential benefits and risks of additional screening, such as ultrasound or MRI, for people with dense breasts.

For now, people in those groups will need to discuss the pros and cons of continued screening — and, possibly, additional imaging — with their doctors to develop a plan that makes sense for their individual circumstances.

Why did the USPSTF change its recommendations?

There were a few important findings that contributed to the panel's decision to change its recommendations, Nicholson says.

First, according to data from the National Cancer Institute, "the number of invasive breast cancer diagnoses among women in their 40s has been increasing every year," Nicholson explains. That number has been increasing by 2% every year since about 2016, she days.

Second, a thorough review of the latest science on breast cancer screening suggested showed the biggest benefit from starting at age 40 and continuing every other year. And, finally, modeling studies that took the starting age, ending age and screening interval into account revealed "the most favorable balance of benefits and harms" from starting biannual screening at 40, Nicholson says.

With this strategy, the panel predicts there will be 1.3 deaths averted — and 1.8 deaths among Black women — for every 1,000 women screened. "So (there's an) even higher benefit for black women who we know are disproportionately affected by breast cancer deaths," Nicholson says.

Overall, the panel predicts this screening regimen can save around 20% more lives than the previous recommendations.

However, Dr. Elisa Port, chief of breast surgery for the Mount Sinai Health System and director of the Dubin Breast Center, tells that biannual screening for aggressive breast cancers isn't enough — even if that screening starts at 40.

"That's kind of talking out of both sides of (your) mouth," she says. "Every other year is not an interval that's appropriate. You can miss aggressive breast cancers (because they) grow quickly."

Dr. Therese Bevers agrees. While she was pleased to see the USPSTF's decision to start screening at age 40, she tells that she's "disappointed" the task force chose to stick with screening every other year rather than recommending annual mammograms.

While it's not the case for everyone, "we tend to see breast cancers that are more aggressive in younger women," says Bevers, medical director of the Cancer Prevention Center at the University of Texas MD Anderson Cancer Center.

Those more aggressive and life-threatening cancers are "specifically the ones we want to find as early as we possibly can," Dr. Laura Dean, breast imaging radiologist at the Cleveland Clinic, tells "We want to find them with screening so that they don't get to the point where they're palpable to the patient." 

For that reason, "I feel that it probably is even more important for women in their 40s to get an annual mammogram (than older women)," Bevers says.

But Nicholson says the latest science indicates that the benefits of a mammogram every year don't outweigh the risks. Data from national observational studies "does not show any further advanced cancers in those who are screened every other year compared to every year," she says.

Getting screened every year also significantly increases the likelihood for potential harms, Nicholson says. Those harms include false-positive results, which can result in unnecessary biopsies, among other treatments and tests.

But not all patients are averse to that kind of testing, even if it turns out to be unnecessary, Bevers explains. "Yes, women who get an annual mammogram are going to get more callbacks," she says, "however, most women do not feel harmed by it." 

In her experience, "I am commonly told by the woman, 'Thank you all for taking such an effort to make sure there is nothing going on.' And they find a great deal of reassurance from that," says Bevers, who also leads the National Cancer Care Network's breast cancer screening guidelines panel.

Research shows that women who have a biopsy that ends up being negative still want to keep getting screened, Dean says, pointing to a 2014 study in JAMA Internal Medicine. The study also found that, while a false-positive mammogram increased anxiety in the short-term, it did not lead to long-term anxiety.

"If you look at the benefit of screening — the whole point of doing all of this is to save lives from breast cancer — the benefits far outweigh those perceived harms," she says.

How other breast cancer screening recommendations compare

If these new guidelines sound familiar, it might be because other major groups already recommend that women with an average risk for breast cancer start getting mammograms around age 40 or 45. However, they disagree on how often to get screened and at what age screening should stop.

“The recommendations are now more closely aligned between the task force and other society guidelines,” Dean says, “but they still differ, especially in that frequency of screening.” 

For example:

  • The American Cancer Society guidelines say that women ages 40 through 44 should have the option to start screening annually. Between the ages of 45 and 54, people should definitely get screened every year. At age 55, women can choose to have mammograms every year or every other year and should continue as long as they are in good health and expected to live for another 10 years.
  • The National Cancer Care Network recommends annual mammograms starting at age 40.
  • The American College of Obstetricians and Gynecologists recommend that women be offered to start mammograms at age 40 and should start no later than age 50. They should choose to have screening every year or every other year based on a thorough discussion with their doctor. And they should continue screening until at least age 75.
  • The American College of Radiology and Society of Breast Imaging recommend annual screening starting at age 40 and a risk assessment by age 25, especially for higher-risk populations, including Black women and women of Ashkenazi Jewish heritage.

Will insurance cover the new screening guidelines?

This is where things get a little complicated.

Under the Affordable Care Act, insurers must cover preventive women's health services — including mammograms — without cost-sharing, meaning at no cost to the patient. For women with an average risk for breast cancer, yearly mammograms should be covered by insurance starting at age 40.

Additionally, under the ACA, Medicare is required to cover any service the USPSTF deems an A- or B-grade recommendation based on the scientific evidence, the Centers for Disease Control and Prevention explain. With the new USPSTF guidelines, biannual mammograms starting at age 40 are now a grade-B recommendation and should be covered at no cost to the patient.

However, Bevers notes that additional imaging for patients with dense breasts is not yet considered an A- or B-grade recommendation. So, although the patient's mammogram may be entirely covered, they may still need to pay at least a portion of the cost for a subsequent ultrasound or MRI.

This may be particularly confusing when, starting this fall, clinics are required by the Food and Drug Administration to notify patients that they have dense breasts and that their breast density may affect the accuracy of mammography, Dean says.

"That's going to cause a lot of confusion for women if the government is saying, by law, we have to tell them that there's limitations," she says, "but we we aren't necessarily providing them with any insurance coverage that might help them to have additional screening."

When should you start screening for breast cancer?

First, you should talk to your doctor about your risk for breast cancer, Port says. That will include a conversation about your age, family history (including on your father's side), genetic risks and results from previous biopsies, for instance.

You should have that conversation even if you don't think you have any risk factors for breast cancer, Dean says, because the vast majority of breast cancers are "diagnosed in patients who have no family history or known identifiable risk factors, and I think a lot of the general population doesn't know that."

Then, you should ask your doctor about screening for breast cancer starting at age 40, and you should absolutely start screening by age 50. Depending on which expert group's recommendations you and your doctor are following, you may get screened every year or every other year at least until age 75.

Remember, those recommendations are only for people who have an average risk for breast cancer. Those with an elevated risk, such as people who have BRCA gene mutations, will follow other recommendations and likely qualify for earlier and more frequent screening.

"Have an early conversation with your doctor about breast cancer screening so that you can decide when is appropriate and how frequently is appropriate for you based on your goals and your risk factors," Dean says.