Women at Average Risk for Breast Cancer Should Start Screening Mammograms at Age 40

By Andrea Peirce,

Monday, January 11, 2016

Digital mammogram units as shown here with MSK Breast Imaging Chief Elizabeth Morris and a patient generate more vivid and precise images than older film screening technology is able to capture.

On January 11, the US Preventive Services Task Force made an official recommendation that women at average risk for breast cancer undergo regularly scheduled screenings from age 50 to 74. It also recommends that women in their 40s make decisions on screening frequency based on conversations with their doctor. This news arrives several weeks after the American Cancer Society updated their recommendations. Memorial Sloan Kettering experts continue to advise average-risk women begin regular screenings at age 40.

  • The US Preventive Services Task Force recommends that women at average risk for breast cancer begin screening mammograms at age 50 and continue every other year until age 74.
  • The panel recommends that women in their 40s make a decision about when to begin annual breast screening based on conversations with their doctor.
  • The guidelines differ from what the American Cancer Society recommended in October 2015, which is to initiate annual mammogram screening at age 45.
  • After reviewing the evidence, Memorial Sloan Kettering breast cancer experts continue to recommend that women at average risk begin breast screening at age 40.

“Women’s confusion over when to start breast cancer screening just continues to grow,” says Memorial Sloan Kettering Breast Imaging Chief Elizabeth Morris in response to the release of new US Preventive Services Task Force (USPSTF) guidelines today. The recommendations from the independent volunteer panel come just months after the American Cancer Society (ACS) issued its own updated guidelines.

The input from yet another well-respected organization following an in-depth review of scientific evidence on the benefits and harms of screening mammography as well as input from health care professionals and the public has once again brewed confusion and left countless women wondering if they’re doing the right thing. 

“The bottom line — and what our Breast Service has recommended for years now — is that women at average risk for breast cancer start getting screening mammograms at age 40,” says Dr. Morris. “We know this approach saves lives. MSK’s breast cancer screening guidelines are not changing in any way in light of recent recommendations from other organizations.”

Why Guidelines Sometimes Differ

There’s actually little disagreement among experts around the world that mammography screening for breast cancer saves lives, notes Dr. Morris. “What differs depends on the greatest relative value that the committee doing the evaluation places on certain things.”  

For example, she says, groups such as the ACS have placed the most weight on minimizing challenges for women associated with potential overdiagnosis, false-positive readings, and the need for additional procedures. As a result, the group recommends average-risk women start annual mammograms at age 45 and transition to screening every two years at age 55.

In contrast, MSK places the greatest emphasis on what’s been shown to save the highest possible number of lives: annual mammograms beginning at age 40. Groups most focused on minimizing biopsies and repeat scans, on the other hand, recommend that women start annual mammograms at age 50 and continue every other year — as do groups that place the greatest value on keeping costs down.

“Ultimately, the decision about when to start screening is a very personal one,” explains Dr. Morris. “A woman will have to talk with her doctor, decide for herself what she is comfortable with, and proceed from there.”  

The USPSTF takes care to note that “mammography is an important tool for women ages 40 to 74.” And the ACS guidelines, authored by a committee headed by MSK primary care physician Kevin Oeffinger and published in the Journal of the American Medical Association, qualify their recommendations to a point by noting that women ages 40 to 45 “should have the opportunity to start screening early if they choose.”

The USPSTF and ACS guidelines address screenings only for women at average risk for breast cancer, not for women at increased risk.

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Newer Breast Screening Tools Alter the Picture

Another thing to keep in mind when considering the USPSTF and ACS guidelines, Dr. Morris notes, is that the screening data are based on mammography technology that is “decades-old film screen technology.”

At MSK and most other screening centers across the United States and around the world today, screening mammograms are done with digital technology that generates a much more precise and vivid image than film screen technology is able to capture. As a result, some of the drawbacks that so many experienced at one time, such as misdiagnoses and getting called back for repeat images, are not nearly as common as they once were.

“We’ve progressed so much,” explains Dr. Morris, “and gotten so much more sophisticated and advanced in breast screening technology. 

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Is it true that if you have/had a brother who got prostate cancer at a you age, it increases your risk for breast cancer? (He was 47 :-(

It's possible that your brother's cancer was caused by a gene that he inherited, but most prostate cancers are not hereditary. If you're concerned about your family history, we recommend you speak to a genetic counselor. If you're interested in speaking to someone in MSK's Clinical Genetics Service, you can call 646-888-4050 or go to https://www.mskcc.org/cancer-care/risk-assessment-screening/hereditary-… for more information. Thank you for your comment.

I'm completing my 2nd year of screening. They will do an ultrasound on me next. I have calcifications and dense breasts. How likely do you think this is cancer?

Thank you for reaching out. We suggest you discuss this with your physician, as every person's individual risk is affected by a number of factors.

I am Followed at the surveillance program @mskcc. We have the braca gene in stern all side. Also my only sister. Mother died of met breast cancer at 68. When should my daughter start being screened? She is 36

If you are already being followed by MSK's surveillance program, we recommend that you discuss this with your healthcare team there, or ask them for a referral to one of our genetic counselors. Thank you for your comment.

I am disappointed in MSK. Does MSK at least tell women under 50 who come for a screening mammogram what the false positive rate is, before they receive the test? Choice is good but only if it is well informed.

To clarify, a "false positive" means that there is a question on the screening mammogram that indicates more testing should be done, usually additional mammogram pictures and/or an ultrasound. It does not mean that a woman is told she has cancer when she does not. In addition, these "false positives" can occur at any age, not just in women under 50. Thank you for your comment.

Kudos to MSK for sticking to your recommendations! It is not good enough for women to be told that they can "choose to get screened earlier if they prefer" because if that's not the recommendation, insurance will probably find a way not to pay for it. More institutions such as yours need to speak out on this.

It means aged women have a higher risk for breast cancer? Am I right?

Chloe, yes it is correct that your risk of developing breast cancer increases as you get older. Thank you for your comment.

My younger sister has very recently been diagnosed with breast cancer and I'm wondering whether I should be tested to see if I carry the gene that makes me prone also. I am 53 years old.

Hello MSK,
Can anyone come to MSK for a breast screening? or must there be a suspicion of breast cancer to become an MSK patient?
Thank you.

I've been getting mammography since I'm 24, also ultrasounds. This pass year had biopsy of right breast 18 of them. They put markers in my right breast.I have dense breast also cycstic. Father died from lung cancer. My mom had uterine and her sister had breast cancer. Other two sisters also had cancer. Do you think I need to go every year to be tested. I'm 65.

Gail, this is something that you should discuss with your doctor. If you are concerned about your family history of cancer, you may want to contact a genetic counselor. If you're in the New York area, our Clinical Genetics Service can be reached at 646-888-4050. You can go to https://www.mskcc.org/cancer-care/risk-assessment-screening/hereditary-… for more information. Thank you for your comment.

My sister died from breast cancer at age 45. There was no known family history at that time. Since that a number of family members have been diagnosed with breast, kidney and esophageal cancers. My question is, what happens after age 74? Do they stop screening?

Lynn, you should discuss this with your doctor. According to Dr. Morris, there is no particular age at which we recommend stopping screening. The general rule is that you should keep screening annually if you have at least a ten-year life expectancy. So a woman in poor health at age 70 who may not live another 10 years likely shouldn't undergo screening, whereas a healthy 80 year old should. Thank you for your comment.

I am 58 years of age I been taking receiving mammogram since the age of 35 I have something called fibrocystic breast when I turn 50 it was recommended that I take sonogram works for me when you have a fibrocystic breast its very painful when you're taking a mammogram your breast hurt for at least 2 days after taking a mammogram if not more when you have a fibrocystic breast you always have pain in your breast your breast are very tender

25 years ago I had a biopsy of my left breast
because of calcification. Some calcification existed in the right breast also, however, my
Dr. Advised that there was grouping together and
more in the left. I had digital mamo this past fall.
At 75 do I need to have a mamo every other year?
My biopsy was done at MSK by Dr Petric who
died tragically a number of years ago. I found her
through my niece who was a nurse at MSK.
Thank you

Patricia, we recommend that you discuss this with your doctor. According to Dr. Morris, there is no particular age at which we recommend stopping screening. The general rule is that you should keep screening annually if you have at least a ten-year life expectancy. So a woman in poor health at age 70 who may not live another 10 years likely shouldn't undergo screening, whereas a healthy 80 year old should. Thank you for your comment.

Does MSK offer both breast cancer and ovarian cancer surveillance for BRCA + individuals? And if so is it a team approach? I find it bizarre that no one I have found so far does this. Instead I'm sent one place for mammos and another place for trans vag ultrasounds another place for CA-125 another place for MRI and my busy OBGYN can't exactly keep up. Doesn't make me feel very safe at all.

Anna, thank you for your question. Memorial Sloan Kettering does offer screening for breast and ovarian cancer for BRCA-positive individuals. Although it isn't all done by one team, all imaging is performed at MSK and kept within one system. Patients are seen by the RISE (Risk Assessment, Imaging, Surveillance, and Education) Program for breast cancer screening and the Gynecology Service for ovarian cancer screening. The screening itself is performed by specialists in these services.

To learn more about our RISE program, you can go to https://www.mskcc.org/cancer-care/risk-assessment-screening/screening/i….

Interesting, my GYN recommended a mammogram at 35, suggesting most doctors would recommend the same. I have no genetic predisposition/family history. She said that insurances will cover it as well.

I was diagnosed with stage 2 ER+ Breast cancer at age 48 less than a year after a clear mammogram, with no family history. I felt the lump, and it did not show up on a mammogram, only on an ultrasound. I had been told I had dense breasts, but had no idea that was a risk factor in an of itself. I think it is important to make sure that Breast density and ultrasound bids are part of the screening conversation, and that women really understand what it means when they make their choice to have mammograms and ultrasounds at 40,45 or 50.

I am always thankful for Elizabeth Morris and for Dr. Monica Morrow, both of whom diagnosed and treated my Ducal Carcinoma in the summer of 2014. I came in with a questionable Mammogram and Ultra-Sound from a Radiology
Group in New Jersey which told me to come back in 6 months. With your expertise, and further studies by Elizabeth Morris, I was diagnosed with Ducal Carcinoma within one week. I am cancer free and will be back this summer for my follow-up mammography with you. Thank your or your professionalism, and care. My family and I are all grateful. Laurie Esposito, Palin, NJ

Dear Laurie, we are glad to know you are doing well and have felt well-cared for by the staff at MSK. Thank you for sharing your experience.

If I had followed ACS guidelines, I would be dead before my first screening at 45. With no family history, and believing I was in excellent physical shape (normal blood work, exercising 5x a week, healthy BMI, eating well-balanced organic diet) I was diagnosed with stage 4 metastatic breast cancer at 41. At my annual checkup at 40, my doctor didn't recommend a mammogram and I didn't even think to ask for it. She examined my breasts and told me I was fine. I felt in such excellent shape, with no history of cancer, It didn't even cross my mind to question it. 7 months later I felt a tiny lump and was diagnosed within a week stage 4 ER/PR/Her2 + breast cancer spread to the bones. If only my doctor recommended a mammogram at my visit a few months prior. If only...

Tsiliana, thank you for sharing your story. Best wishes to you.

Last week my gyno said protocol changed for having a mammo and ultrasound at same time when you have dense breasts. He said to have ultrasound 6 months after mammo. I'm very concerned about this. I've also had thyroid cancer. Should I insist on them both together?

Dear Christine, we sent your question to Dr. Morris and she responded:

"Every six month screening with a different test is certainly an option however if it is more convenient for you to do them at the same time that is also an option. There is no evidence to favor one strategy over the other. The important message is to do both mammography and ultrasound if you have dense breasts."

We hope this is helpful. Thank you for reaching out to us.

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