USPSTF stops short of recommending supplemental imaging for women with dense breast tissue

Amid the release of new breast cancer screening recommendations from the United States Preventive Services Task Force (USPSTF), experts, medical organizations and advocates alike are coming forward saying that the new guidelines “do not go far enough,” particularly when it comes to addressing the needs of women with dense breasts

The new guidelines recommend that all women at average risk undergo screening mammograms every other year starting at age 40. Previously, the recommended age was 50. 

Although the update is in line with recommendations from numerous medical societies, the biennial aspect is not. Most, including the American College of Radiology, endorse annual screening. 

USPSTF's cancer screening recommendations for women with dense breasts

USPSTF determined that “more research is needed about whether and how additional screening might help women with dense breasts stay healthy,” thereby, not recommending the use of supplemental imaging. 

In an editorial published Tuesday in JAMA Oncology, Wendie Berg, MD, PhD, professor of radiology at University of Pittsburgh School of Medicine, said the impact dense breast tissue has on mammographic performance was “minimized,” before detailing the numerous risks associated with increased density. Berg also highlighted the added benefits of supplemental screening in women with dense breasts. 

“Digital breast tomosynthesis minimally improves detection of cancers in dense breasts compared with digital mammography (DM) and can replace DM, but it is not supplemental screening,” Berg wrote. “Other tests, especially MRI, improve detection of node-negative invasive breast cancer.” 

In women with dense breast tissue, the ACR advises yearly breast MRI exams starting at age 40, but such imaging was not included in the latest recommendations. Neither was breast ultrasound nor contrast-enhanced mammography (CEM), both of which are more easily accessible, less expensive alternatives to breast MRI. 

Although supplemental screening may be readily available for some women, financial barriers maybe prevent many from seeking additional screening if an exam is not covered by insurance. The Affordable Care Act mandates coverage of routine breast cancer screening, but it does not require that insurers pay for imaging exams beyond that. 

Many states have laws in place requiring insurers to cover supplemental imaging, but the specifics vary widely and there is no guarantee that out of pocket costs would not incur. An official endorsement from USPSTF likely would have removed this barrier.

What will it take for supplemental imaging to be included in screening guidelines? 

In an email to Health Imaging, Dr. Berg noted that although there is good clinical evidence to support some forms supplemental imaging, more research is needed before the recommendations fall in line. 

“We have good data on incidence screening results for MRI and ultrasound already, but we need such results for CEM,” Berg said, adding that the type of information that comes from clinical trials is also of importance. “The question remains whether the USPSTF will only consider randomized trials, in which case we may need additional such trials of MRI and CEM in women with dense breasts, particularly if that is their only risk factor.” 

Berg highlighted multiple trials examining the use of supplemental imaging for dense breast tissue that are currently taking place or have just been completed, sharing that she is looking forward to the results. And although she believes the updated recommendations are a step forward, they still stop short of what is needed. 

When should women stop screening? 

Many providers also took issue with recommendations to stop screenings in women over 74. This is in contrast to guidance from the ACR, which recommends that women continue screening “unless severe comorbidities limit life expectancy.” 

Similar to their call for more research into supplemental imaging, USPSTF also emphasized an “urgent” need for more research on the benefits and harms of continuing biennial screening beyond the age of 74. 

The updated recommendations can be viewed here

Hannah murhphy headshot

In addition to her background in journalism, Hannah also has patient-facing experience in clinical settings, having spent more than 12 years working as a registered rad tech. She joined Innovate Healthcare in 2021 and has since put her unique expertise to use in her editorial role with Health Imaging.

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