USPSTF: Begin Breast Cancer Screening at Age 40 (Not 50) Years for All Women

Screening for breast cancer for all women should begin at age 40 years and continue every other year, according to a new draft recommendation from the United States Preventive Services Task Force (USPSTF).

The recommendation, made public on Tuesday, May 9, 2023, is an essential reversal of the USPSTF's 2009 guidance that raised the recommended age for routine assessment to 50 years from 40.

The 2009 recommendation advised that women of all racial and ethnic backgrounds between ages 40 and 49 years and at average risk for breast cancer make individual decisions about when to start screening based on health history and personal preference and begin regular screening upon turning age 50, according to a USPSTF statement. The risks of earlier screening researchers believed at the time, could potentially outweigh he benefit, leading to unnecessary and invasive testing and treatment, the Task Force said.

Earlier diagnoses, high Black mortality

The new recommendation that all women should begin regular screening at age 40 years is in response to accumulating data that show an increase in the annual rate of breast cancer diagnoses among women younger than age 50 years and persistently high mortality rates among Black women in particular. The shift, says USPSTF, "could result in 19% more lives being saved."

Black women are more likely to be diagnosed with later stage breast cancer and at younger ages than other racial or ethnic groups and are more likely than White women to have aggressive disease, according to USPSTF. Moreover, Black women are approximately 40% more likely to die from breast cancer than White women. The higher mortality rate persists after accounting for age differences and stage at diagnosis and despite the similar or higher rate of self-reported mammography screening among Black women vs all women (84.5% vs 78%, respectively).

Black women are approximately 40% more likely to die from breast cancer than White women. The higher mortality rate persists after accounting for age differences and stage at diagnosis and despite the similar or higher rate of self-reported mammography screening among Black women vs all women (84.5% vs 78%, respectively).

In the draft statement USPSTF notes that the elevated breast cancer mortality among Black women in the US aligns with other inequities in health status that are attributed to “the effects of structural racism, which include inequalities in resources, exposures to environmental harms, and access to and delivery of high-quality healthcare.

"The Task Force recognizes this inequity and is calling for more research to understand the underlying causes and what can be done to eliminate this health disparity."

“Ensuring Black women start screening at age 40 is an important first step, yet it is not enough to improve the health inequities we face related to breast cancer,” said Task Force vice chair Wanda Nicholson, MD, MPH, MBA. “In our draft recommendation, we underscore the importance of equitable follow-up after screening and timely and effective treatment of breast cancer and are urgently calling for more research on how to improve the health of Black women.”

Recently scientists have called for a move away from the current universal, one-size-fits-all approach screening toward a “risk-adapted” approach, which would mean screening Black women at least 8 years earlier than White women and the USPSTF recommendations appear to be headed in that direction.

The Task Force states that evidence is currently insufficient to recommend for or against screening mammography in women aged ≥75 years. There is also insufficient evidence regarding the effect of supplemental screening using breast ultrasonography or MRI on health outcomes in women with dense breast tissue whose mammogram findings are otherwise normal.

The new USPSTF recommendation applies to all people assigned female at birth who are asymptomatic and at average risk for breast cancer, including those with dense breast tissue and a family history of breast cancer.

Other professional societies

Currently the American Cancer Society (ACS) recommends women at average risk for breast cancer begin regular screening mammography at age 45 years and until aged 54 years be screened annually. Women aged ≥55 years should transition to biennial screening with the opportunity to continue annual assessment. Women aged 40 to 44 years should have the option to begin annual screening mammography. ACS states that women should continue regular assessment for breast cancer as long as their overall health is good, and their life expectancy is ≥10 years.

The American College of Obstetricians and Gynecologists recommends that women at average risk of breast cancer should be offered screening mammography starting at age 40 years, using shared decision making, and if they have not initiated screening in their 40s, should begin by no later than age 50 years. Screening should continue every 1 or 2 years until at least age 75 years. Beyond age 75 years, the decision to discontinue screening mammography should be based on shared decision making informed by the woman’s health status and longevity.

The American Academy of Family Physicians supports the current USPSTF recommendation on screening for breast cancer.

The Task Force’s draft recommendation statement, draft evidence review, and draft modeling report have been posted for public comment on the Task Force website. Comments can be submitted from May 9, 2023, to June 5, 2023.