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Women should start screening for breast cancer at age 40 instead of 50, health task force says in draft recommendation
The US Preventive Services Task Force is proposing that all women at average risk of breast cancer start screening at age 40 to reduce their risk of dying from the disease, according to a new draft recommendation statement.
It’s an update to the 2016 recommendation, in which the task force recommended that biennial mammograms, which are x-rays of the breasts, start at age 50 and that the decision for women to screen in their 40s “should be an individual one.”
Some groups, such as the American Cancer Society, already have been recommending for women to start mammograms in their 40s.
“Our new task force recommendation is recommending that women start screening with mammography for breast cancer at age 40 and screen every other year until age 74,” said USPSTF Vice Chair Dr. Wanda Nicholson, a senior associate dean and professor at George Washington University’s Milken Institute School of Public Health.
The USPSTF, a group of independent medical experts whose recommendations help guide doctors’ decisions and influence insurance plans, released the proposed update to its breast cancer screening guidance Tuesday. The recommendation is not final but will be available on the task force website for public comment through June 5, along with a draft evidence review and draft modeling report.
The draft recommendation is for all people assigned female at birth, including cisgender women, trans men and nonbinary people, who are at average risk for breast cancer.
Nicholson said that women with dense breasts and those with a family history of cancer generally fall into this category but not women who have a personal history of breast cancer or a family history of genetic mutations, like mutations on the BRCA gene, as they are considered to be at high risk.
The updates would not apply to those at an increased risk of breast cancer, who may already have been encouraged to screen at 40 or earlier. They should continue to follow the screening practices that their doctors have recommended.
Breast cancer is the second most common cancer among women in the United States, and rates of death are highest among Black women.
‘Screening alone is not enough’
The update to the recommendation “will save more lives among all women,” Nicholson said. “And this is particularly important for Black women, who are 40% more likely to die from breast cancer.”
The draft recommendation comes a few weeks after a study in the journal JAMA Network Open found that the rate of breast cancer deaths among women in their 40s was 27 per 100,000 person-years for Black women, compared with 15 deaths per 100,000 in White women and 11 deaths per 100,000 in American Indian, Alaska Native, Hispanic and Asian or Pacific Islander women. The researchers suggested that Black women start screening at younger ages, around 42 instead of 50.
The USPSTF members are calling for more research into these racial inequities in breast cancer, Nicholson said, and for all women who get abnormal mammogram results to receive equitable follow-up evaluations, additional testing, biopsies and treatment when needed.
“Screening alone is not enough. Once someone screens with an abnormal mammogram, the subsequent steps in care must occur – timely follow-up, biopsies that are indicated – and Black women must have access to equitable treatment,” she said.
“We’re calling for more research to look across the health systems as to why these inequities occur,” she said, adding that the draft recommendation also calls for more research into whether women with dense breasts should get additional screening and among “women who are 75 years of age and older, whether and how to screen that population.”
Cases in younger people
To review and update breast cancer screening guidance, the task force members analyzed data from thousands of study abstracts and hundreds of research papers on screening programs, cancer cases and deaths in the United States.
They found that screening with mammograms every other year provided a moderate benefit to women ages 40 to 74, as the benefits, such as detecting cancer early, outweigh potential harms, such as the risk of a false positive that could lead to unnecessary tests and emotional stress.
The evidence is “insufficient” to determine the risks and benefits for screening in women 75 and older, the group determined. The task force also noticed that the rate of breast cancer diagnoses has been rising each year among women at younger ages.
Population-based data “showed that the rate of breast cancer diagnoses was increasing at 2% annually since 2015. So more women than ever before are being diagnosed in their 40s,” Nicholson said.
An estimated 12.9% of women born in the United States today will develop breast cancer at some time during their lives, according to the National Cancer Institute.
“Within our recommendation, we’re calling for more research to have a better understanding of the causes and mechanisms that may be contributing to breast cancer development in all women, and in particular among Black women,” she said. “We know that Black women continue to have more aggressive tumors.”
A paper published in October in the journal Nature suggests that the incidence of various cancers diagnosed in adults 50 and younger has been rising in many parts of the world since the 1990s.
“The rising incidence of early-onset cancers is probably partially attributable to increasing uptake of screening and early detection before the age of 50 years, to variable degrees across certain cancer types, especially breast, prostate and thyroid cancers,” the researchers wrote.
“However, increasing incidence of early-onset cancers in several organs, such as colorectal and pancreatic cancers, which might not be fully explained by screening is also apparent,” the researchers wrote. “This trend could reflect increased risk factor exposures in early life and/or young adulthood.”
To screen biennially or annually?
The draft recommendation appears to be catching up with what other organizations have been recommending for some time.
It aligns more closely – but not entirely – with American Cancer Society recommendations that women ages 40 to 44 have the option to screen with a mammogram every year, women 45 to 55 get mammograms every year, and women 55 and older can switch to a schedule of mammograms every other year.
“There are some similarities and some differences. So, now, the new task force recommendations has changed from screening at age 50 to age 40. And our recommendations currently are that women should begin to have the opportunity to begin annual screening if they choose beginning at age 40. The big difference there is, we recommend annual screening at that age, while the task force recommends biennial screening,” said Dr. William Dahut, chief scientific officer of the American Cancer Society, who was not involved in the USPSTF draft recommendation.
“But the big thing is, I think, a lot of women were being screened probably starting in their 40s, and so this is consistent, I think, with how most women and practitioners have been looking at screening,” he said.
Both the USPSTF and the American Cancer Society recommendations are for women at average risk. Dahut said that women should talk to their doctors about whether they might have a higher risk for breast cancer and what screening practices would be best for them, including factors like a family history of ovarian or breast cancer or dense breasts, which have less fatty tissue and more connective tissue and have been associated with a higher risk of breast cancer.
“The change in guidelines by the USPSTF to endorse screening mammograms for average risk women 40 and over is warranted, incorporates more modern and ‘real world’ data into the science informing the guidelines and will hopefully prompt payers to provide better coverage for women seeking breast cancer screening,” Dr. Laura Dominici, a breast cancer surgeon at Dana-Farber/Brigham and Women’s Cancer Center, said in an emailed statement. She was not involved in the USPSTF draft recommendation.
“This is particularly important related to racial disparities in screening, as Black women are more likely to develop aggressive cancers at younger ages, contributing to worse outcomes,” Dominici said. “I am glad to see inequities in screening being acknowledged, but more attention to this will be needed in future guidelines.”
Still, the new draft recommendation will not change how Dr. Maxine Jochelson discusses breast cancer risks and the important of screening with her patients, she said.
“Unfortunately, the fact that they’re still recommending every other year rather than yearly screening, and in particular in the younger population, is very disappointing,” said Jochelson, chief of the breast imaging service at Memorial Sloan Kettering Cancer Center in New York, who was not involved in the USPSTF draft recommendation.
“You are going to miss earlier cancers if you’re waiting longer, and younger women and Black women often have more aggressive cancer,” she said. “I’m going to still tell them to have yearly screening.”
注释：
biennial: adj
表示" 两年一次的；两年生的"，means "occurring every second year"，如：The workers were strongly against the biennial election. 工人们强烈反对两年一次的选举。
mammogram; n
表示" 乳房X线照片"，means "X-ray film of the soft tissue of the breast"，如：Here, we emphasize the preference for sonogram over mammogram. 在此我们强调在诊断此种疾病时，超音波优于乳房摄影。
mammography: n
表示" 早期胸部肿瘤X射线透视法"，means "a diagnostic procedure to detect breast tumors by the use of X rays"
cisgender
表示"一个人的生理性别与其行为或其扮演的角色完全匹配"
nonbinary: adj
表示"非二进制的"，如：nonbinary code 非二进制码
mutation: n
表示"突变；变异"，means "a change or alteration in form or qualities"，如：Our teacher has mutation of sounds suddenly. 我们的老师突然语音发生了变化。
Hispanic: n; adj
1. n表示" 讲西班牙语的人；美籍西班牙人"，means "an American whose first language is Spanish"，如：My identity has evolved as being Hispanic,although I'm only half-and-half.我的血统虽然一半一半，可身份最后还是被确定为拉美裔。
2. adj表示"西班牙的；西班牙语的"，means "related to a Spanish-speaking people or culture"，如：Hispanic immigration has brought more Catholics. 西班牙移民带来了更多的天主教徒。
biopsy: n
表示" 活组织检查"，means "examination of tissues or liquids from the living body to determine the existence or cause of a disease"，如：Later that evening, I had a biopsy. 那天晚上，我接受了活组织检查。
outweigh: v
表示" 比 ... 重要；比 ... 有价值"，means "weigh more heavily;"，如：The merits of your plan outweigh the defects. 你制定的计划其优点胜过缺点。
incidence: n
表示"发生率，发生范围"，means "the relative frequency of occurrence of something"，如：Each incidence of truancy will impact the citizenship credit. 每次发生玩忽职守事件都会影响公民的信用。
prostate: n
表示" 前列腺"，means "a firm partly muscular chestnut sized gland in males at the neck of the urethra; produces a viscid secretion that is the fluid part of semen"，如：The prostate is a small gland in men. 前列腺是男性体内的一个小腺体。
thyroid: n
表示"甲状腺"，means "of or relating to the thyroid gland"，如：This is controllable with thyroid supplements.这是可控制的与甲状腺补充。
colorectal: adj
表示" [解]结肠直肠的"，means "relating to or affecting the colon and the rectum"，如：Likewise, the diet did not protect women from colorectal cancer. 同样,这种饮食也不能保护妇女不患直肠癌。
pancreatic: adj
表示"胰脏的"，means "of or involving the pancreas"，如：The boundary of liver lobule and pancreatic lobule was obscure.肝脏和胰脏的小叶界限不清晰。
ovarian: adj
表示"卵巢的"，means "of or involving the ovaries;"，如：Ovarian cancer is a malignant tumour in the ovary.卵巢癌是生长在卵巢的恶性肿瘤。
中文简要说明：
根据调查，乳癌是国人十大癌症死因之一，死亡率年增10.2%，比其他癌症都要高；世界卫生组织（WHO）2020年报告也指出，全球每年约有68.5万名女性死于乳癌。美国卫生机构昨（9）日宣布，女性应从40岁开始接受乳癌乳房X光摄影筛检，比过去建议的年龄提早10年。
根据美国有线新闻网（CNN）、《华盛顿邮报》报道，由美国卫生部任命、由独立专家群组成的「美国预防工作小组」（U.S. The Preventive Services Task Force）9日发布声明，建议40至74岁女性每两年进行一次乳房X光摄影检查。该小组成员之一、塔夫茨大学医学院教授黄柏成（John Wong）说，40多岁女性罹患乳癌的比例每年增加2%，速度惊人，降低筛检年龄可以多挽救约20%的生命。
报道指出，非裔女性在40岁前罹患乳癌的风险高于白人女性，死亡率也较高。不过这项降低筛检年龄的建议属于预防医学范畴，不适用于已经做过乳房切片检查、确诊乳癌或高风险的女性，这些人应该寻求医生的意见。
此外，该建议也尚未针对拥有「致密性」乳房（dense breast）、或缺乏足够乳房组织的妇女，是否应接受超音波或核磁共振摄影作为补强措施，给予明确的指示。致密性乳房指的是脂肪组织比例较低、结缔组织（connective tissue）较高，使一般乳房X光检查的能力下降，但通常这些妇女也较有可能罹患乳癌。
黄柏成表示，目前尚未有足够证据，可以证明超音波或核磁共振摄影对致密性乳房的利弊。他呼吁医学界加速研究，让更多妇女的健康获得保障。
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