Have candid talks with patients about breast-cancer screening

The U.S. Preventive Services Task Force (USPSTF) now recommends that women start regular mammograms at 40 years old.

This updates the 2016 recommendation on biennial screening for women 50 to 74 years old, which called for individualizing the decision to undergo screening for women 40 to 49 old years based on their health history, preferences and how they value different potential benefits and harms.

The previous recommendation led to fewer screenings and more women under 50 presenting with advanced stage breast cancer, experienced Adrienne Hansen, MD, a radiologist at Confluence Health, which is a member the AMA Health System Program that provides enterprise solutions to equip leadership, physicians, and care teams with resources to help drive the future of medicine.

Physicians and other health professionals are relieved that USPSTF updated their recommendation, changing the recommended screening age back to 40, said Dr. Hansen, noting “the major benefit of screening mammography is the proven reduction in breast cancer mortality by up to 40% compared to unscreened women.” 

Screening mammography catches cancers at earlier stages, leading to more favorable outcomes than in advanced, clinically-apparent cancers in patients not undergoing screening mammography, “particularly node-positive cancers,” she said. Catching early cancers through screening also results in less expensive, less morbid treatments. 

It is critical that doctors and patients share decisions about starting, ending, and determining frequency of screening, said Elizabeth Avena, MD, a family physician at Confluence Health. 

“We have an open dialogue with patients regarding their individual risk, benefits versus harms of screening, and also explore their personal values and goals,” said Dr. Avena. “We want our patients to feel they have adequate information to understand their screening options and take an active role in their health care decisions.”

Here is how Confluence Health embraces shared decision-making for breast cancer screening and ensures patients receive the best care.

Dr. Hansen advises that patients begin annual screening for breast cancer at 40 years old. Such screening should continue until they’re at an age where they would no longer consider treatment if a cancer was found or, if in consultation with a primary care physician, feel they would no longer gain benefit from screening mammography. 

“Although radiologists follow the American College of Radiology’s screening guidelines, we keep up to date with recommendations from other societies and the USPSTF, so that we can best answer questions posed by our patients. We do let the patient know that there are other societal recommendations for screening,” she said. Candid discussions take place about age, frequency of testing, and beating the odds of disease. 

Breast-cancer incidence begins a sharp rise at 40, peaking at age 74 , so screening at 40 and after age 74 makes sense. If a cancer is found at a two-year interval, it may be larger and more advanced than at a one-year interval.

But Dr. Hansen also informs patients that most breast cancers in older women tend to be slow-growing and the mortality or long-term outlook may not change at two-year screening intervals.

It is important that patients understand ahead of time that a mammogram is a screening test and that an abnormal result does not mean a breast cancer diagnosis, said Dr. Avena. Nationally, out of every 10 recalls an average of six will require additional imaging and be assured that there is no sign of cancer. Two women will be asked to return in six months for a follow up, and two women will require biopsy. We provide patients with information about call backs at the time of their screening study.

“We call patients with abnormal results who need additional views to help alleviate anxiety,” said Dr. Avena. For normal results, Confluence Health communicates per patient preference through the EHR or a letter. 

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Dense breasts are associated with both reduced sensitivity and specificity of mammography and with an increased risk of breast cancer. The USPSTF found that there is insufficient evidence to assess the balance of benefits and harms of supplemental screening for breast cancer in women identified to have dense breasts on an otherwise negative screening mammogram. The task force urgently called for more research on whether and how additional screening might help women with dense breasts, and on the benefits and harms of screening in women 75 or older.

However, the U.S Food and Drug Administration and the State of Washington require radiologists to notify patients about their breast density, and the possibility that supplemental imaging may be helpful in detecting cancer. 

“We are fortunate that Washington State passed diagnostic and supplemental imaging legislation, which took effect in January 2024. This new law does not apply to every commercial insurance plan, so checking with an insurance company is still recommended,” said Dr. Hansen. 

Mammography is not a perfect examination. “There is a risk of a mammographically occult tumor,” which is a breast cancer that is not visible on a mammogram, “particularly in dense and extremely dense breasts, and a negative mammogram may confer false reassurance,” said Dr. Hansen. 

Another perceived harm is stress caused by additional imaging. Screening may result in a finding which requires follow-up imaging or biopsy that turns out not to be cancer. Anxiety from inconclusive mammograms is brief with no lasting health effects. Nearly all women who have had a false positive exam still endorse regular screenings.

Confluence Health employs only fellowship-trained, dedicated breast imagers who have lower callback rates and increased positive predictive values of biopsy recommendations and biopsies performed, noted Dr. Hansen. Between 2022 and 2024, her medical group’s recall rate was 9.2% and the cancer-detection rate (per 1,000) was 7.6. 

“A radiologist needs to read enough mammography to find the balance where they call back enough screening mammograms, and biopsy enough findings, to catch the most cancers,” she said. 

A patient’s personal values and preferences should always be considered in the screening process, said Dr. Avena.

“It is an opportunity to provide education, help patients take an active role in their health care decisions, and understand the potential benefits and consequences of a decision,” she said.

An average-risk 40-year-old patient, for example, may decide she’s more comfortable with annual screening versus biannual, accepting the increased risk of false positives and potential biopsies. 

“That should be her decision as long as it is informed and falls within guidelines,” said Dr. Avena.