The new draft breast screening recommendations from the United States Preventative Services Task Force are a step in the right direction. However, important revisions are needed to do better for women and further reduce the suffering, cost and loss of life from this disease.
Our official public comment is below. We hope you add your voice to the public comments to implore the USPSTF to reduce confusion and create a screening recommendation with the best chance of saving more families from cancer.
REMINDER: Comments on the draft USPSTF guidelines are due by midnight June 6th. To submit a comment, please click HERE.
Volpara Health Statement on New USPSTF Breast Cancer Screening Recommendations
Thank you. While public comment periods typically usher in criticism, it’s important to commend the task force for taking steps to improve breast screening recommendations for “average”-risk patients.
Americans look to our government for guidance. Your recommendations, alongside those of the FDA and medical societies, determine—for so many—patient adherence. Reducing conflicting recommendations and aligning the starting age from 50 to 40 is good news. It reduces patient confusion and hesitation and acknowledges that approximately nine percent of all breast cancers occur in women under age 45. These cancers tend to be more aggressive and harder to treat. Starting to screen annually at age 40 will save lives.
However, we implore you to address and rectify the following aspects of your recommendations to do better for women and further reduce the suffering, cost, and loss of this disease. The public health opportunity is too great to wait another decade, and the science available today supports:
Annual screening. Yearly mammograms reduce breast cancer mortality by up to 40 percent. This is because annual screening helps women find cancers earlier in less aggressive stages. Beyond reducing pain and suffering, we can reduce the 2.5–4x increase in treatment costs when a cancer is found in stage 0 vs. stage IV. Interval cancers, found after a “normal” mammogram, but before the next scheduled mammogram, tend to be more aggressive. Research published by Boston University in the May 25, 2023, Journal of the American College of Surgeons found that delays in screening due to Covid resulted in a 14.6 percent decrease in breast cancer diagnoses, which is reflective of missed mammograms, additional imaging, and biopsies. This is likely to lead to more later-stage disease and, tragically, loss of life after detection. Biennial screening compounds these Covid delays and gives cancers more time to grow.
We encourage closer collaboration across all branches of the US government for clearer, more consistent recommendations and to protect access to breast cancer screening care. An important priority should be support for reenacting the PALS Act, which requires insurance reimbursement of annual mammograms despite USPSTF biennial guidance.
Supplemental imaging for women with dense breasts. Women with dense breasts must have access to imaging beyond mammograms. Nearly 50 percent of women over age 40 have dense breast tissue. Screenings in addition to mammograms, such as ultrasound and MRI, drastically improve detection at earlier stages in dense breast tissue. Rigorous research shows that dense breast tissue makes it harder to find breast cancer on a mammogram and raises the risk of developing breast cancer. In women with the densest tissue, about 40 percent of cancers are missed on a mammogram. In March 2023, the FDA issued a final rule reflecting and acknowledging the overwhelming science indicating that women with dense breasts need extra screening. This rule requires providers to tell women if they have dense
breasts, and if they do, instructs them to discuss options beyond mammograms with their providers.
The USPSTF’s request for more dense breast tissue research is unfounded. There is longitudinal, irrefutable evidence to support the need for extra imaging in dense breast tissue. The USPSTF’s approach creates confusion, sows doubt, and is dangerous. The US government owes its people clear, evidence-based guidance. Current evidence supports recommending ultrasound, MRI, or even contrast-enhanced mammography to women with dense breast tissue. This has been proven at a national level in the Netherlands. The 10-year prospective DENSE trial showed that identifying women with extremely dense breasts and offering them breast MRI led to a significant drop in interval cancers without increasing false positives. We request that the task force do a literature review on breast density, cancer risk, and supplemental imaging outcomes. Women with dense breast tissue are not at “average risk” and should have clear recommendations beyond mammography.
Risk assessment before age 30. The USPSTF draft guidelines specifically highlight the increased risk for black women, which is a step forward. However, the guidelines are disconnected from the strong medical consensus from the American College of Radiology, the Society for Breast Imaging, and the American College of Obstetricians and Gynecologists, all of whom agree that all women should have risk assessment by age 25 to determine if they are at elevated risk and would benefit from early or more intensive screening and prevention. Further, other demographics that often present as “high risk,” such as Ashkenazi Jews, are not specifically named in the guidance. Issuing guidelines for “average”-risk patients assumes that people know their risk. This rarely happens in practice and requires the government to recommend risk assessment for all women over age 25. The task force has an opportunity to align with these knowledgeable societies by updating the recommendations now to create a true shift to individualized care.
Thank you for your consideration of these revisions. They present an opportunity to improve patient care and save more American families from cancer.