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Leading Breast Radiologists Discuss the USPSTF Breast Cancer Screening Recommendations
In recognition of National Women’s Health Month, Dana Bonaminio, MD, Amy Patel, MD, and Stacy Smith-Foley, MD, shared their thoughts and perspectives on the recently updated breast cancer screening recommendations from the United States Preventive Services Task Force (USPSTF).
Discussing the value of annual mammography exams, supplemental ultrasound and MRI screening, and continued mammography exams for women 75 and older, Dana Bonamino, MD, Amy Patel, MD, and Stacy Smith-Foley, MD, shared their perspectives on the recently updated breast cancer screening recommendations from the United States Preventive Services Task Force (USPSTF).
Dr. Smith-Foley noted that prior USPSTF breast cancer screening recommendations, issued in 2009, created confusion by recommending that mammography exams begin at the age of 50 in women at average risk of breast cancer. Dr. Smith-Foley and Dr. Bonaminio praised the USPSTF’s latest breast cancer screening recommendations for “realigning” with the American College of Radiology (ACR) and the Society for Breast Imaging (SBI) in emphasizing a starting age of 40 for mammography exams in this patient population.
Emphasizing the Need for Annual Mammography Screening
However, Drs. Bonaminio, Patel and Smith-Foley all expressed disappointment with the USPSTF’s emphasis on biennial as opposed to annual mammography screening.
“I remain disappointed with the recommended interval (every two years) for routine screening. These recommendations only lead to more confusion for our patients and primary care colleagues (at the least) and potentially allow for the progression of undetected breast cancers (at the worst),” maintained Dr. Bonaminio, the director of breast imaging at Ascension St. Thomas Midtown Center for Breast Health in Nashville. “We know that early detection of breast cancer saves lives - annually screening remains critical. In most cases, finding a breast cancer while still small allows for less aggressive surgical and systemic treatment, leading to better outcomes and a chance for cure.”
Dr. Patel emphasized that multiple organizations, including the ACR, SBI and the American Society for Breast Surgeons, have recommended annual mammography exams beginning at the age of 40 for women at average risk of breast cancer.
“When women skip their mammogram intentionally or unintentionally, … we tend to find more advanced disease,” pointed out Dr. Smith-Foley, the medical director of the Breast Center at the Central Arkansas Radiation Therapy Institute (CARTI) in Little Rock, Arkansas. “The breast cancer is larger, it is more extensive, it is more often a higher grade and more frequently involves the axilla with local regional metastasis. What I see in clinical practice is that when we have these gaps or delays (with mammography screening), the disease is more extensive.”
While Dr. Patel noted a lack of trial data comparing annual versus biennial breast cancer screening, she said the USPSTF modeling studies help improve the understanding of screening outcomes over time and different populations.
“After a comprehensive analysis, the latest science continues to demonstrate that, when one balances the lives saved against harms such as unnecessary follow-ups and treatment, women benefit more when screening is performed every year,” emphasized Dr. Patel, the medical director of the Liberty Hospital Breast Care Center in Kansas City.
Addressing Supplemental Imaging in Women with Dense Breasts
While the USPSTF noted insufficient evidence for the use of supplemental MRI and ultrasound for women with dense breasts, Drs. Bonaminio, Patel and Smith-Foley all emphasized the essential nature of supplemental imaging in this patient population.
Drs. Smith-Foley and Bonaminio noted that dense breast tissue can hide or mask breast cancer on mammography exams, and Dr. Bonaminio emphasized that nearly 40 percent of women over the age of 40 have dense breasts. In her clinical experience, Dr. Smith-Foley said the missed breast cancers on mammography in this patient population are often “higher-grade, more aggressive tumors.”
In her practice, Dr. Smith-Foley recommends supplemental ultrasound for women of average breast cancer risk with heterogeneously dense or extremely dense breasts. For women with an elevated breast cancer risk, defined as a 20 percent or greater lifetime risk, Dr. Smith-Foley recommends supplemental MRI.
Dr. Patel said the use of abbreviated MRI has “been incredibly useful” in serving a diverse population in her practice and noted that multiple studies have demonstrated the effectiveness of supplemental screening for women with dense breasts.
Recent research from Weinstein and colleagues revealed a cancer detection rate of 27.4/1000 for abbreviated MRI in women with dense breasts and prior negative findings on digital breast tomosynthesis (DBT), according to Dr. Patel. She added that studies from Berg and colleagues have also shown that adding breast MRI to mammography results in a higher yield of breast cancer detection and a lower false positive rate than the combination of ultrasound and mammography.
“ … All organizations and governing bodies need to be on the same page when it comes to these tools which can also lead to less invasive treatments when malignancies are caught earlier on these supplemental examinations,” maintained Dr. Patel, an associate professor at the University of Missouri-Kansas City. “This also has broader implications for insurance coverage for patients, and although we are seeing a moderate number of states passing some form of supplemental screening coverage in patients with dense breasts at varying levels of breast cancer risk, we need to strive for federal legislation to ensure all patients have uniform access.”
A Closer Look at Breast Cancer Screening for Seniors 75 and Older
While the USPSTF noted a 22 percent decrease in breast cancer mortality with annual mammography screening between the ages of 70 to 74, they found no evidence of mortality reduction with mammography screening between ages of 75 to 84.
Dr. Smith-Foley said the research about the lack of mammography-related mortality reduction in women 75 and older is deceiving.
“Statistically, you only see (breast cancer) risk flatten in women over the age of 75 because they begin to die from other causes. It’s not that their mortality isn’t affected by (mammography) screening, it’s that they develop comorbid conditions,” pointed out Dr. Smith Foley.
“All women’s lives are worth saving,” said Dr. Bonaminio, the Women’s Imaging National Subspeciality Lead for Radiology Partners. “We have a subset of women who obtain yearly screening mammograms into their 80s or even older. If our patients remain in good health, it is reasonable to encourage continued mammographic screening to allow for the benefits of early detection in our patients over 75 years of age.”
“A woman’s risk for developing breast cancer continues throughout her life,” maintained Dr. Smith-Foley. “If she has breasts and she has birthdays, she has risks.”
Similar to Dr. Bonaminio, Dr. Smith-Foley sees a number of seniors over the age of 80 in her practice and has seen presentations of locally advanced breast cancer that could have been detected at an early stage with yearly screening. She recalled one case in which supplemental ultrasound made a significant difference for an 85-year-old woman with dense breasts.
“We found a high-grade breast cancer that had metastasized to her axillary lymph nodes, and this was completely occult on mammography. If we hadn’t gone the extra mile in continuing to screen her and we hadn’t given her supplemental screening with ultrasound, we wouldn’t have made the diagnosis,” emphasized Dr. Smith-Foley.
Final Notes
For future updates to the USPSTF breast cancer screening recommendations, Dr. Bonaminio called for “more comprehensive guidelines fully addressing the importance of risk assessment, especially for our at-risk populations including Black women and Ashkenazi Jewish women.”
Dr. Patel concurred and noted that she hopes to see change in future USPSTF screening recommendation updates that would include addressing risk assessment at the age of 25 for high-risk women, patients with dense breasts, screening in women over the age of 74, and screening recommendations for the transgender community.
“We must continue to encourage the (USPSTF) to address these aspects of breast imaging care, and advocate for our patients as we strive as a breast cancer community to improve insurance coverage, care and outcomes,” said Dr. Patel, a past president of the American Association for Women Radiologists.
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