In May 2023, the United States Preventive Services Task Force (USPSTF) issued new draft recommendations for breast cancer screening that, notably, lowered the age at which women should start screening from 50 to 40 years old.
With expertise from several BCRF investigators, below, we answer common questions about these new guidelines—and highlight where screening research is moving in the future.
The USPSTF is one of seven leading independent organizations and panels that make breast cancer screening recommendations and other cancer care guidelines. Such reports can influence things like insurance coverage and help care providers decide on the best screening schedules for their patients.
In short, the task force now recommends women:
From 2009 until recently, the USPSTF recommended that women with an average breast cancer risk between the ages of 50 and 74 get screening mammograms every other year. The USPSTF did not recommend all average-risk women aged 40–49 be screened—unlike other task forces and independent organizations—and instead advised that women make individual decisions with their doctors about starting in their 40s.
The USPSTF’s new guidelines lowered the age to start screening down to 40 instead of 50. In revising its previous stance, the USPSTF’s guidelines are now more aligned with other groups’ recommendations. Most other organizations recommend women start screening or be offered the choice to start screening at age 40.
The USPSTF did not revise its stance on whether women should be screened every year or every other year; in these draft recommendations, it continues to recommend that women be screened every other. Other organizations recommend annual screening in their guidelines.
Additionally, the USPSTF highlighted the need for more research into screening disparities faced by different racial groups in the U.S. and into the benefits of breast ultrasound and MRI for women with dense breasts. The task force also noted that it did not have sufficient studies to make specific recommendations about screening women 75 and older.
The task force releases recommendations as a draft to solicit feedback and public comment before releasing final recommendations. Major changes to the draft are not anticipated.
The new recommendations reflected two major trends—both thanks to “new and more inclusive science,” the task force wrote. First, research has shown that more women in their 40s are being diagnosed with breast cancer, so the benefits of screening this group outweigh potential harms.
The USPSTF also acknowledged that Black women—who are 40 percent more likely to die from breast cancer than white women—are more likely to be diagnosed in their 40s and with more aggressive breast cancers. Screening these women earlier will no doubt save more lives, but the task force also noted that it needed more research to determine if Black women should be screened on a different schedule entirely.
“It’s so important that these experts keep up with the latest research and continue to update their recommendations,” BCRF investigator Dr. Connie Lehman, who was not involved with the draft recommendations, said in an interview. “[This] has been an area of controversy for over 50 years, and over the decades, we found that different organizations had different perspectives on the same research.”
In short, differing guidelines reflect organizations’ unique approaches to weighing the benefits of screening against potential harms like false positives and overtreatment.
Lehman noted that what makes the USPSTF’s notable now is that the recommended age was lowered to 40.
“We’re coming to a consensus on age that we haven’t had before,” she said.
The major benefit of screening is that it helps detect breast cancer sooner. When breast cancer is caught early, it is nearly 100 percent curable. Women diagnosed with early-stage breast cancers can also be cured with fewer and/or less-intense treatments and surgeries. Mammograms and breast cancer screening have saved millions of lives.
On the other hand, screening does come with potential risks and harms. Though mammography is the best tool we currently have, it is not perfect. Women may be given false positive results that require biopsies and additional imaging—causing unnecessary stress. Younger women tend to have dense breasts, which can make it harder to distinguish normal breast tissue from suspicious tissue, leading to more false positives, as well.
In some cases, a woman may undergo surgery based on a false positive for cancer that wasn’t there to begin with or be treated for a suspicious area that may never have progressed to full-blown invasive breast cancer.
Recommendations like USPSTF’s try to balance the benefits of screening for a certain group against things like false positives and overtreatment. With more women 40 to 49 being diagnosed, the USPSTF found the net benefits won out for this group now.
Experts like BCRF’s Founding Scientific Director Dr. Larry Norton said the recommendations were “moving in the right direction” but pointed out that most other organizations recommend annual mammograms—not biannual. USPSTF’s guidelines on frequency did not change.
“Annual screening is critically important,” he said. “Having a smaller cancer improves the chance of a cure and also makes it easier for us to achieve that cure with less surgery, less systemic therapy, and better quality of life.”
Another reason frequency is so important: Breast cancers in younger women tend to be faster growing.
“We know that if a woman is diagnosed in her 40s, it is more likely to be a more aggressive type of breast cancer,” BCRF investigator Dr. Mehra Golshan wrote in an op-ed for the New York Times. “This is the kind of cancer that is best to catch early because the treatment will need to be more intensive as it progresses—likely requiring a combination of surgery, radiation and drugs like chemotherapy. This isn’t the same situation as a woman who comes to me with an early-stage cancer at age 80.”
Dr. Norton also noted that the task force did not give recommendations on additional types of screening (ultrasounds, contrast-enhanced mammography, MRIs) that can detect breast cancer in women with dense breasts, who tend to be younger.
No. In the U.S., insurers are required to cover annual mammograms for women 40 and over.
If you are in your 40s and haven’t started screening, talk to your doctor about your personal risk for breast cancer and ideal screening schedule at your next appointment.
The American College of Radiology (ACR)—another independent organization that advises on screening—recently recommended that all women get a breast cancer risk assessment by age 25. Black women and women of Ashkenazi Jewish ancestry especially, the ACR wrote, needed to have this assessment done because of their higher risk for the disease.
If you’re 25 or older and haven’t had a risk assessment, now is the time to do so with your care provider. This can help your doctor determine if you should be screened earlier than 40.
If you and your doctor determine that you don’t need earlier screening, pay attention to changes in your breasts and get anything suspicious checked out.
The task force’s updated recommendations highlight the critical need to move from an age-based approach to breast cancer screening to a personalized, risk-based approach. BCRF research is focused on improving both breast cancer risk assessment and screening tools themselves.
Under a risk-based screening model that harnesses technologies like artificial intelligence and machine learning, women will get individualized screening recommendations on when to start and how frequently to be screened, based on factors like family history, genetics, ethnicity, and more. Coupling a risk-based model with improved screening technologies (such as contrast-enhanced mammography) has the power to drastically improve early detection.
“I am so excited that we’re at a point in medical history where we have new tools to finally move from a very crude, imprecise, age-based screening for breast cancer to the precision of risk-based screening to detect breast cancer,” Dr. Lehman said. “It’s unbelievable that we have this opportunity now. But we have a lot of work to do to actually get women on a risk-based protocol.”
A risk-based approach to screening also helps ensure that women aren’t left behind by guidelines—whether that’s because of their age, race, or other factors, BCRF’s Chief Scientific Officer Dr. Dorraya El-Ashry said.
“A one-size-fits-all approach to screening recommendations creates vulnerable populations,” she said. “Personalized, risk-based screening should be the ultimate goal. Research can and is helping us identify and even quantify that risk, better informing decisions around screening.”
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