Why the Before Forty Initiative is So Vital
ASBS: Mammogram Studies Suggest Use in Younger Women
By Charles Bankhead, Staff Writer, MedPage Today
May 03, 2011
WASHINGTON -- Excluding younger women from routine screening mammography
may increase the risk of larger, more advanced tumors at diagnosis and adversely
affect survival, data from a retrospective chart review suggested.
Among women younger than 50, tumors diagnosed by means other than
mammography were 50% larger and three times as likely to have lymph node
involvement, according to Paul S. Dale, MD, of the University of Missouri in
Columbia, and colleagues.
The risk of recurrence was almost six times higher, and both disease-free and overall
survival were substantially lower among women who did not have mammographically
"Mammography detected cancers in women ages 40 to 49 that were smaller, had
less nodal metastasis, and were associated with increased survival," Dale said here
during a press briefing at the American Society of Breast Surgeons meeting.
"Excluding women in this age group from routine mammograms will potentially result
in later disease diagnosis and poorer survival rates for women ages 40 to 49."
Another study reported at the meeting suggested that failure to perform routine
mammography in younger women may miss opportunities for early diagnosis of
hormone-receptor positive, HER2-negative, and triple-negative tumors, particularly
among women of minority groups.
In 2009 the U. S. Preventive Services Task Force (USPSTF) ignited a firestorm of
controversy with revised breast cancer screening recommendations that encouraged
individualized decision making about mammography for women ages 40 to 49.
Previously, annual screening had been the norm for all women, beginning at age 40.
Almost immediately, proponents of annual screening at age 40 criticized the
recommendation for creating confusion and putting younger women at increased risk.
Played out largely in the media, the arguments and counterarguments reached a
point of such contention that HHS Secretary Kathleen Sebelius found it necessary to
release a statement emphasizing that the USPSTF does not set health policy.
The studies reported at the ASBS meeting approached the controversy from a "what
if" perspective, examining potential risks and consequences if younger women
diagnosed with breast cancer had been omitted from routine mammographic
"Breast cancer mortality rates have been declining since 1990," said Dale. "Mortality
rates have significantly decreased in women younger than 50, and this decrease has
been attributed to earlier detection of presymptomatic breast cancer through
To examine potential consequences of not screening younger women, Dale and his
team reviewed breast cancer records for a 10-year period and identified women
whose disease was diagnosed before age 50.
The review resulted in a study population comprising 145 women with
mammographically detected breast cancer and 166 whose cancer was diagnosed by
Comparison of the two groups showed that nonmammographically detected breast
cancer had a strong association with high-risk features:
Larger size, 30.38 mm versus 20.68 mm
Nodal involvement, 85 (56%) versus 28 (25%)
Positive family history, 38 (25%) versus 19 (15%)
Recurrence, 40 (23.4%) versus 7 (5%)
Additionally, women with mammographically detected breast cancer had a five-year
disease-free survival of 94% versus 71% for nonmammographically detected cancer
and overall survival of 97% versus 78%.
Even when detected at an early stage, breast cancer in younger women tends to be
higher risk, data from the second study showed.
Those findings came from an analysis of 46,700 women who had diagnoses of ductal
carcinoma in situ (DCIS) or T1N0 breast cancer included in the California Cancer
Registry from 2004 to 2008.
The study population included 10,566 women ages 40 to 49 (22.6% of the total), said
Sharon Lum, MD, of Loma Linda University in California.
Comparison of clinical and demographic features of younger (40 to 49) and older (50
to 74) patients showed that the cancers in younger women were significantly more
likely to be:
Hormone receptor positive, OR 1.85 (DCIS) and OR 1.43 (T1)
HER2 positive, OR 1.46 (T1)
Triple negative, OR 1.67 (T1)
Younger women with DCIS or T1 disease were significantly more likely to be from
minority racial/ethnic groups (OR 1.44 to OR 1.82).
Excluding women ages 40 to 49 from mammographic screening could affect early
diagnosis of high-risk cancers and would disproportionately affect minorities, possibly
leading to diagnosis of more advanced-stage disease, said Lum.
Primary source: American Society of Breast Surgeons
Dale P, et al "Mammography in 40-year-old women: The potential impact of the U.S.
Preventative Services Task Force (USPSTF) mammography guidelines" ASBS 2011;
Additional source: American Society of Breast Surgeons
Aragon RJ, et al "The potential impact of USPSTF recommendations on the early
diagnosis of breast cancer" ASBS 2011; Abstract 1670.
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