When the Guidelines Still Equate to a Death Sentence: The USPSTF Must Do More

The U.S. Preventative Services Task Force issued new guidance this week that says women should get screened for breast cancer every other year starting at age 40. While Tigerlily Foundation is excited about this change, as it will undoubtedly save many lives, we push to ask for more. This proposal is beneficial to young women and those diagnosed with triple negative breast cancer (TNBC), a faster growing and harder to treat form of breast cancer, which largely affects young Black and Hispanic women – the most vulnerable populations.

However, we are missing critical pieces of the puzzle still. While this new guidance lowers the screening age, it is disappointing that the recommendation is only biennial and that the guidelines give secondary screening for women with dense breasts an “I” grade for insufficient evidence. Once again, the very population at most risk and that bears the brunt of inequities in breast healthcare, young Black women, are the group that typically have dense breasts. The facts are that:

? Black women also tend to have denser breast tissue than White women, which can make it more difficult to identify breast cancer on a mammogram, and women with dense breast tissue have a higher risk of breast cancer.

? Black women are three times more likely than white women to be diagnosed with triple negative breast cancer and have the lowest survival rate at each stage of diagnosis Women who are diagnosed with triple negative breast cancer (TNBC) are 53% more likely to be under 40 years old:

? Black women under 35 get breast cancer at twice the rate of White women, and die at 3 times the rate.

? Triple-negative breast cancer is more common in young women, and those diagnosed with breast cancer under the age of 40 are twice as likely to have TNBC than those between the ages of 50 and 64.

While we applaud the progress that the USPSTF has made by lowering the recommended age to 40, there still needs to be consideration for more vulnerable populations. We cannot allow young women to continue going undiagnosed and ultimately losing their lives unnecessarily. In addition, with these recommendations, women 75 years and older are dissuaded from getting screenings. With people now living longer, this is very troubling as we should not take away someone’s choice of whether or not to get screened, and whether or not to choose to get treated if diagnosed. Some time ago, I shared my plans on the importance of educating young women and healthcare providers and transforming systems and recommendations that do not work for younger women. I had the honor of presenting it to Rep. Debbie Wasserman Schultz. Our subsequent conversations led to the creation of groundbreaking legislation, the EARLY Act, which was passed in 2009, sponsored by Rep. Wasserman Schultz. The EARLY Act increased public awareness, research, and resources around the threats posed by breast cancer to young women, especially women of color, and the importance of early detection. It also led to the creation of nationwide awareness and programs supporting young women at risk for and living with breast cancer.

Then in 2014, Tigerlily prioritized leading the Protecting Access to Lifesaving Screening (PALS) Act, going on the Hill and advocating to ensure that screening recommendations wouldn’t be changed to an even higher age, as well as to remove access and cost barriers for young women. We have been advocating for years for what is right and just for young women. All in all, USPSTF’s proposal addresses what Tigerlily has been advocating for since 2009 – but they must do more. In the 14 years that it’s taken the task force to adjust its recommendation to allow for screening at 40 years old, thousands of young women have died. We need to accelerate policy change to ensure that underrepresented populations have access to lifesaving screening sooner.

Let’s continue to be relentless as we work to close the gaps so that all communities have access to the quality breast healthcare that they need and deserve.

Tigerlily Medical Advisory Board Member & Medical Commentary:

“Average-risk women in America will benefit greatly from the updated USPSTF mammography screening guideline which recommends that screening be iniated at age 40 years. The prior guideline, which recommended that women delay initiation of screening mammography until they reach age 50, was based upon historic mammography studies that did not adequately reflect the benefits of the contemporary technology for young women, and they did not include any significant numbers of African American women. The older USPSTF guideline therefore completely failed to address the breast cancer burden of African American women, who are more likely to develop breast cancer at younger ages, more likely to develop biologically aggressive tumors such as TNBC at all ages, and more likely to have aggressive tumor biology even when they are diagnosed with non-TNBC patterns. For all of these reasons, screening mammography beginning younger than age 50 is essential in our efforts to eliminate breast cancer disparities through early detection. While I applaud the USPSTF for reversing their prior guideline in favor of supporting mammography screening at age 40, I believe that we can optimize the benefits of screening with annual mammography rather than the biennial schedule suggested by the USPSTF.” -Lisa Newman, MD, MPH, FACS, FASCO, Chief of the Section of Breast Surgery, New York-Presbyterian/Weill Cornell Medical Center and Weill Cornell Medicine

“The new USPSTF recommendations are a step forward in the right direction. The data is overwhelming that annual screening beginning at age 40 for average risk women is the path we must take to save the most lives. Breast cancer in younger women is harder to find and more aggressive, so this is laudable. However, the USPSTF recommendations falls short in not recommending annual screening for all and not definitely recommending screening for women over 75. This is a mistake that will cost lives. The new recommendations also address the unacceptable disparity in breast cancer diagnosis, treatment and survival in underserved and high-risk populations such as Black women and Ashkenazi Jewish women. Their recommendation for additional research is not enough. We have data that demonstrates additional, earlier screening is critical. Finally, the need for additional screening for women with dense breast tissue is essential to find the mammographically hidden, invasive breast cancers so that we can detect and diagnose the earliest, most curable breast cancers.” -Rachel Brem, MD, Vice Chair of Radiology, Director, Breast Imaging and Intervention Center, George Washington University

"It is encouraging the USPSTF has modernized their recommendations to include women 40-49 for screening mammography because early detection and intervention save the most lives. While this is a good step forward, I hope incoming data will further their recommendations to be annual mammography rather than biennially for optimal patient outcomes in this younger population." - Nicole Saphier, MD, Director of Breast Imaging, Memorial Sloan Kettering Cancer Center Monmouth

“The draft USPSTF recommendations are moving us forward, and I applaud the inclusion of young women aged 40-49 years as this will impact more lives. However, we need continued efforts to identify the most effective imaging modalities (or combination of imaging), including at the extremes of age. The incidence of breast cancer is rising in young women and a challenge in this typically unscreened population is identifying those at higher risk of developing cancer. These young women should begin an appropriate high risk surveillance protocol. Other challenges remain, such as the well-known disparities faced by young Black women, and the need to define the best supplementary screening for those patients identified as having mammographically dense breast tissue. Individualized, tailored treatment plans are most effective when combined with early detection and young women will benefit from continued research about best strategies for screening.” - Cristina M Checka, MD, Associate Professor, Department of Breast Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas