AAPA talks with USPSTF about its new breast cancer screening recommendation

The US Preventive Services Task Force (USPSTF or Task Force), an independent volunteer panel that issues guidance on clinical preventive services, recently published its latest recommendation on screening for breast cancer.¹

Annamarie F. Streilein, MHS, PA-C, American Academy of Physician Associates (AAPA) member and senior faculty at Duke University Medical Center, asked several key questions about this new recommendation to Task Force chair and obstetrician-gynecologist Wanda Nicholson, MD, MPH, MBA, to highlight what physician associates/assistants (PAs) and their patients need to know.

AAPA: What do PAs and their patients need to know about the new Task Force recommendation, and to whom does it apply?

USPSTF: The Task Force recommends that all women get screened for breast cancer every other year starting at age 40 years and continuing through age 74 years to reduce their risk of dying from this disease. This is a B grade recommendation.

We are also urgently calling for more research that will allow us to build on our existing guidance and help all women live longer and healthier lives. Specifically, we need to know how best to address health disparities across screening and treatment experienced by Black, Hispanic, Latina, Asian, Pacific Islander, Native American, and Alaska Native women.

Additionally, we need studies on what more should be done for women with dense breasts, and we need evidence on the benefits and harms of screening in women ages 75 years and older. These are I statements.

Our recommendation applies to cisgender women and other people assigned female at birth who are age 40 years and older. It includes women at average risk of breast cancer, as well as those with a family history of breast cancer and those with dense breasts. The recommendation does not apply to people who have a personal history of breast cancer, who are at very high risk of breast cancer because of certain genetic markers or a history of high-dose radiation therapy to their chest at a young age, or who have had a high-risk breast lesion on previous biopsies. These women should consult their healthcare professionals for individualized guidance about screening.

In the Task Force's review of the evidence, it found no trial data that compared annual and biennial screening. Although annual screening might find some cancers earlier, it is not clear whether this would improve women's health or change the way their cancer progresses, and screening every year increases harms. As a result, the Task Force concluded that screening every other year leads to a better balance of benefits and harms than annual screening.

AAPA: How has this recommendation changed from the previous Task Force recommendation on this topic?

USPSTF: Although we have consistently recognized the value of mammography, the latest science makes it clear that we can save even more lives from breast cancer by having all women start getting screened at age 40 years. Previously, we recommended that women in their 40s make an individual decision with their clinician about when they should start screening, taking into account their health history, preferences, and how they value the different potential benefits and harms.

The Task Force now recommends that all women start getting screened for breast cancer every other year starting at age 40 years. Basically, it's a shift from recommending that women start screening between the ages of 40 and 50 years to recommending that all women start getting screened when they turn 40.

AAPA: Why did the Task Force's recommendation change for women in their 40s?

USPSTF: This change was driven by two major factors. First, more women in their 40s are getting breast cancer, with rates increasing about 2% each year—which means there is more potential benefit to screening. Second, our modeling was able to use new data on screening in the United States and to look at outcomes specific to Black women for the first time.

It is now clear that screening every other year starting at age 40 years has the potential to save about 20% more lives from breast cancer among all women, and there is even greater potential benefit for Black women, who are about 40% more likely to die of breast cancer.

AAPA: What should PAs tell their patients who have dense breasts, given the insufficient evidence for follow-up testing from the Task Force?

USPSTF: Nearly half of all women have dense breasts, which increases their risk for breast cancer and means that mammograms may not work as well for them. Women are generally told that they have dense breasts after they've had a mammogram. These women deserve to know whether and how additional screening might help them stay healthy. Unfortunately, there is not yet enough evidence for the Task Force to recommend for or against additional screening with breast ultrasound or MRI. We are urgently calling for more research on whether and how additional screening might help women with dense breasts find cancers earlier.

It is important to note that all women, including those with dense breasts, should be screened starting at age 40 years. While we call for more research, women with dense breasts should talk with their clinicians about their options for follow-up testing so that they can get the care that's right for them.

AAPA: What guidance should PAs give to their patients who are ages 75 years and older?

USPSTF: The Task Force found that there is not enough evidence to make a recommendation for or against screening in women ages 75 years and older, so we issued an I statement and are calling for more research for this group.

In the absence of evidence, these women should decide together with their clinicians what is best for their individual healthcare needs, based on their preferences, values, and health history. In the future, we hope that more studies on the effectiveness of screening older women are conducted and published so that we can make a more definitive recommendation on how best to care for these women.

AAPA: The Task Force and AAPA both share a commitment to improving health equity. What does this recommendation do to help address the health inequities related to breast cancer?

USPSTF: Across all topics, we consider how our recommendations may help eliminate health inequities and look to identify the drivers of these disparities. For breast cancer specifically, we know that Black women are 40% more likely to die of breast cancer than White women and too often get aggressive cancers at young ages. Ensuring Black women start screening at age 40 years is an important first step, but it is not enough to improve these inequities. It's important that healthcare professionals, including PAs, involve patients in conversations on how best to support them to ensure equitable and appropriate follow-up after screening and timely and effective treatment of breast cancer. We also need more evidence to better understand whether Black women could potentially be helped by different screening strategies.

The Task Force deeply cares about women's health, and we are urgently calling for more research on the underlying causes of this disparity and others experienced by many women related to factors including race, ethnicity, social determinants of health, and geographic location, which could affect treatment processes and access to screening.

AAPA: To reiterate, the take-home message for PAs is that the USPSTF recommends that all women get screened for breast cancer every other year starting at age 40 years and continuing through age 74 to reduce their risk of dying from this disease. This is a B grade recommendation.

Evidence-based recommendations such as this one from the USPSTF that are periodically reviewed and updated serve to provide PAs and other clinicians with information they need to partner with women in shared decision-making; this includes conversation on important conditions such as their breast health.

Based on the recommendations, more research is clearly needed to aid the populations for which the USPSTF could not issue a recommendation either for or against breast cancer screening. This includes screening women ages 75 years and older and performing follow-up screening in women with dense breast tissue. In addition, the USPSTF's call for more research on underlying causes of breast cancer-related health disparities strongly aligns with the AAPA's goal to address health equities among patients.

Note: To learn more about the USPSTF's grade definitions and what they mean for practice, scan here.