Should the breast screening age be lowered?

Prompted by rising rates of breast cancer diagnoses in younger women, the US Preventive Services Task Force (USPSTF) is calling for a revision to the age for mammogram screenings to be lowered by 10 years to age 40.
 
In its final recommendation statement, the USPSTF updated the age from previous advice that women in their 40s ‘make an individual decision with their clinician’ on when they should start screening, taking into account history, preferences, and how they value the different potential benefits and harms.
 
In Australia, breast cancer screening in under 50s aligns with the previous US advice. The RACGP’s Guidelines for preventive activities in general practice (Red Book) recommendations are that women undergo their first mammogram screening at the age of 50, with subsequent mammograms every two years until the age of 74.
 
The question of whether Australia should follow the US and lower the age of screening has previously been asked – and the RACGP maintains the view that the decision to commence breast cancer screening before the recommended age of 50 is up to the individual.
 
Dr Katrina Tiller is a Sydney-based GP and breast physician, and Chair of RACGP Specific Interests Breast Medicine.
 
She told newsGP it’s a nuanced discussion and given that women in their 40s can develop breast cancer, GPs can have those conversations accordingly.
 
‘At age 50, it’s really time to get screened, but at 40, the discussion is there and there are risks and benefits that are different,’ she said.
 
‘That 40–50-year age group are not to be ignored by any stretch, and they shouldn’t be dismissed if they come into the GP and talk about screening – that’s a conversation to be had without a doubt.
 
‘We know women in their 40s get breast cancer, and they’ve got a lot of life to lose if they do get it and it’s picked up later.’
 
Dr Tiller said it’s also important to note that women with symptoms who are not being screened are on a diagnostic pathway, not a mammogram.
 
‘Screening is not about symptoms – if someone’s got a symptom, they’re not being screened, they’re having diagnostic imaging,’ she said.
 
The new US advice comes as data reveals a 2% annual increase in breast cancer diagnoses among US women in their 40s since 2015. The USPSTF says if women in the 40–50-year age group do develop breast cancer, they could be more likely to need chemotherapy, larger surgery, and develop more aggressive cancers.
 
However, while RACGP guidelines cite the obvious benefits of screening, the risks ‘must not be forgotten’.
 
‘Screening mammogram in women aged 40–49 years may reduce the risk of dying of breast cancer, but the number of deaths averted is much smaller than in older women, and the number of false-positive tests and unnecessary biopsies is larger,’ the Red Book states.
 
Overdiagnosis and overtreatment, as well as psychological distress including anxiety and uncertainty from false-positive findings, are also highlighted in the argument against earlier routine screening.
 
Dr Tiller believes the real focus should instead be on increasing BreastScreen participation, with only around 40–60% of the targeted screening group of women over 50 attending.
 
‘We need to put effort into that targeted group, considering 75% of cancers are occurring in women over 50, and 50% of them are not being screened, then that’s where our energies should be going,’ she said.
 
‘Our big picture is we really do need to target that 50% of 50–74-year-olds who are not having their breasts checked so that we can minimise their morbidity, size of their surgery, and the amount of chemotherapy they might have to have and decrease that early mortality associated with a later diagnosis.’
 
With ongoing discussion around screening intervals, age-specific breast screening programs vary around the world. Women in the UK are invited to screen every three years from aged 50–70, while in Sweden, there is a population-based annual screening program from ages 40–74. Other European guidelines are 45–74 and every 2–3 years. New Zealand’s BreastScreen provides a service for women aged 45–69 every two years.
 
And while debate about the best age to start and finish – as well as risks and benefits – plays out around the world, Australians can still attend screening from 40, should they want to, with help from their GP, according to Dr Tiller.
 
‘It’s not pushed, it’s just up to the individual,’ she said.
 
‘If a woman sees [a BreastScreen ad] on the back of the bus, she’s in her 40s and thinks, ‘I’ll go and get my breast check”, she can go get them checked, but it’s not something GPs would routinely recommend.’
 
For now, RACGP guidance remains at routine screening from age 50 every two years.
 
‘After being reviewed recently the decision has been come to that we’re going to stick to the 50–74 age group,’ Dr Tiller said.
 
‘If GPs have a 40-year-old in front of them, they’re thinking about other things at the top of their list, depending of course on her personal history – whether that’s family history, or if she’s had problems with her breasts in the past, or her general risk.
 
‘But if you’ve got a woman in front of you at 50, and she hasn’t had a breast screen yet, then that goes to the top of your list, and really encouraging her to go and get that done.’
 
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