The U.S. Preventive Services Task Force recently recommended lowering the age to begin breast-cancer screenings to 40 years of age from 50. Its report found that screenings every two years from age 40-49 would save 1.3 women per 1,000 screened overall and 1.8 per 1,000 Black women.
“New and more inclusive science about breast cancer in people younger than 50 has enabled us to expand our prior recommendation,” the U.S. Task Force wrote, “and [we] encourage all women to get screened in their 40s.”
Now, regulators in Ontario are recommending women opt-in for preventative screenings beginning at age 40 instead of the province’s current guideline of age 50. British Columbia is also considering this change.
I’m hopeful this new approach can help patients avoid a situation like mine. This month marks the three-year anniversary of my diagnosis with bilateral, Stage 2 breast cancer. After going through major treatments, I’m now on a 10-year regime of adjuvant therapy with my fingers crossed that the cancer won’t re-emerge in metastatic form. I know other women (who, like me, have no known genetic indicators) who were diagnosed with Stage 3 and Stage 4 cancers in their 40s, before they were eligible for screening. I can’t help but wonder if our cancer journeys could have been different with better screening guidelines.
The U.S. report is responding in part to an epidemiological shift. Rates of breast cancer are increasing in women under age 50, an age category that’s also at greater risk of mortality from breast cancer. According to the U.S. Task Force report, the number of invasive breast-cancer cases for 40- to 49-year-old women increased an average of two per cent annually between 2015 and 2019. As the five-year survival for Stage 1 breast cancer is significantly higher than cancers discovered at a later stage, early detection is key to saving lives.
“More health care isn’t always better health care.”
Not everyone in Canada is in favour of changing the screening guidelines. Guylène Thériault of the Canadian Task Force on Preventive Health Care told the Toronto Star her organization is not advising a change in Canada, citing concerns about overdiagnosis causing anxiety and leading to interventions that turn out to be unnecessary. Echoing the overdiagnosis concern, Chris Labos, a cardiologist, wrote in a recent Montreal Gazette Op-ed: “More health care isn’t always better health care. There is a complex balance driven not just by science but also by health-care economics and societal values.”
But Paula Gordon, a Vancouver breast radiologist and professor at the University of British Columbia, has taken issue with concerns about overdiagnosis and patient anxiety. She told the CBC, “If you use that as a reason to not screen, you’re going to miss early cancers you could have found and lives you could have saved.”
How common is overdiagnosis and what are the outcomes? According to a 2022 observational study of more than 900,000 patients screened for breast cancer over a 10-year period, seven to nine per cent were flagged for a biopsy that then proved negative for malignancy.
We can contextualize this number by looking at the FIT colon-cancer test that has a false positive rate of approximately five per cent, requiring further interventions such as colonoscopy. For both colon and breast-cancer screenings, the risks related to a false positive (minor procedures and anxiety – followed by elation) remain low compared with the risks of not having a preventative screening, which include advanced disease and death.
My message to the Canadian Task Force and policymakers is this: Trust women. Trust us to make decisions about our health care. The new U.S. guidance on breast-cancer screening shouldn’t be controversial or a “both sides” issue in Canada. It should serve as a model for the change we need.
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Important discussion on breast cancer screenings and informed decisions! How do you think we can raise awareness about the significance of regular screenings?
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Thank-you Anne Borden King for this opinion piece. Right on!
So happy that Health Minister Duclos has assured us that the Task Force will now use modern data and not rely solely on 40-60 year old RCTS as they have done until now.
https://www.canada.ca/en/public-health/news/2023/06/government-of-canada-to-help-advance-work-on-breast-cancer-screening.html
The 2011 and 2018 Task Force guidelines both recommended against routine screening of women aged 40-49. In the small print, they said that women should have a shared decision-making conversation with their doctor/nurse practitioner and then the decision to have a mammogram was the women’s. That point was very poorly communicated, and as a result, many primary care providers refused to give requisitions and women have suffered as a result. This was clearly shown in research done by University of Ottawa physicians and Stats Canada.
Those discussions should be “informed,” not shared, since it is the woman taking all the risk. The data used in those discussions must be accurate; NOT the decision tools created by the Task Force using data from research that has been shown to be invalid.
Physicians should be obliged to provide those requisitions.
I was dx at age 39 – no family history at all and only symptom was an itchy nipple. I luckily now have a young and aggressive GP who sent me for a mammo and an ultrasound. My mammogram came back 100% clear but my ultrasound detected one small mass. I had a mastectomy where it was determined I had 3 tumours, one almost 4cm directly behind the nipple (and three affected lymph nodes out of 6 removed) – Stage 2b. Had my doctor not sent me for an ultrasound as well, I likely wouldn’t be here now.
My good friend was dx at 31 and passed at 33.
It is a downright abomination that the minimum screening age wasn’t lowered everywhere to 40 ages ago, and a further disgrace that breast density and its relation to cancer has been known since the 70’s and yet women are still almost never told their density. When I was dx not a single woman in my orbit -not one – had ever even HEARD of breast density.
The argument about patient anxiety is a massive, absolute steaming load of bull dung, because after losing a breast, 15 nodes (total) over two surgeries, my ovaries, my hair/brows/lashes, all feeling in my armpit and bottom of my arm (nerve damage from lymph node dissection), feeling in my finger and toe tips (neuropathy from chemo) and having to take hormone blockers daily and bone density injections every 6 months – I can assure you that the scanxiety after all of that FAR outweighs any bit of nervousness you may have from a routine screening that comes out fine, or that even results in a call-back to double check. So, they can take that argument and shove it in the empty bra cup where my boob used to be.
On a sidenote, would like to add that after alllll my active treatment was done, would you believe my doctor tried to send me back to mammos only as my ONLY surveillance?! Really? Was he still afraid of me being “over-screened” leading to me having unnecessary anxiety? Unreal. Even when you actually go through cancer we’re STILL not screened properly after without a fight!
Breast cancer is not a disease of the aged. Younger and younger women are being diagnosed and DYING every single day because of our asinine, outdated & dangerous screening practices. Damn right, trust women! And start trusting us TODAY before one more woman has to be taken into that little room and have her entire world shoved violently and permanently off it’s axis!
Thank you to Anne Borden King for this opinion piece. Currently, only four Canadian jurisdictions: BC, NS, PEI, and YT allow women to self-refer at age 40. Dense Breasts Canada (DBC) is advocating across the country for all women in Canada, no matter where they live, to have the same chance of early detection of breast cancer. Until policies change, our ask of healthcare providers in provinces where a requisition is needed is please stop refusing a requisition to women who wish to be screened. According to the guideline, after a discussion of harms and benefits, the decision to screen is a woman’s, based on her values and preferences. DBC speaks to far too many women who have been unjustly denied a requisition and are suffering the consequences of a later stage diagnosis. Our message to the Task Force and Colleges of Family Physicians is to please ensure providers are aware that the decision to screen at 40 is a woman’s. It’s time to provide clear messaging to healthcare providers and stop the avoidable deaths and suffering.
As a fellow survivor with a similar diagnosis, I concur. The guidelines are not only based on old, flawed research but are administered by a task force that says one thing but guides another, seems intent on infantilizing women (I DO NOT need to be petted on the head thank you) and seemingly has no depth of understanding of the imbalance of power that often exists between many women and physicians. Shared decision-making? Really? So what if your family doctor says no? It happens. Tells you you are too young? It happens. Tells you not to worry it’s just a cyst. It happens. I can volunteer dozens of women who will share similar stories. We need screening to start at a minimum at the age of 40. And we need screening to be annual. Full stop.
I agree fully with the move toward opening organized breast cancer screening programs to women in their 40s. It is long overdue. Role of the health care provider is to provide women with accurate, unbiased information ion screening to they can make their own informed decision. But, especially for women prior to menopause, when cancers tend to faster growing, the screening interval should be annual, not every two years.
I loved the title of this article because that is the message of the Canadian Task Force on Preventive Health Care, that women should be informed in a way that would empower them to make their own decisions about screening. There are benefits but also harms to breast cancer screening and women need to be informed if possible through a process of shared decision making. We are updating our recommendation as we speak to ensure women can have the right information to make the decision that is right for them.