Task Force Breast Cancer Screening Research Articles

Considerations to increase rates of breast cancer screening across populations.

COVID-19 has caused considerable drops in utilization of breast cancer screening services during the pandemic, especially among certain racial and ethnic groups. Members of the Community Oncology Alliance (COA)-including the COA president, South Carolina oncologist Kashyap Patel, MD-have reported increases in patients, particularly those of color, presenting with stage III and IV cancer at diagnosis. According to data released by the Biden administration, more than 9.5 million recommended cancer screenings had been missed in the United States as a result of the COVID-19 pandemic, as of February 2022. President Joe Biden and First Lady Jill Biden, EdD, aim to address this in the 2022 revitalized Cancer Moonshot Initiative. The findings made by COA as well as by Avalere also suggest that the pandemic has exacerbated existing health care disparities. Using a multipayer database, we analyzed breast cancer screening rates for 2 periods-March 1 to September 30, 2019, and March 1 to September 30, 2020-among Medicare fee-for-service (FFS), managed Medicaid, and commercial insurance beneficiaries to understand the potential impact of the COVID-19 pandemic on adherence to the US Preventive Services Task Force breast cancer screening recommendations, which are currently undergoing review. Screening rates were evaluated across 5 racial/ethnic groups and by payer type. Mean monthly mammogram screening rates among eligible White Medicare FFS beneficiaries dropped to 0.6% in April 2020, but these screening rates recovered to 6.5% by June 2020. Screening rates for eligible Black Medicare FFS beneficiaries recovered on a pace slightly slower than that of White beneficiaries, but more rapidly than that of other groups. By comparison, American Indian/Alaska Native beneficiaries had a mean monthly screening rate of 0.5% in April 2020, which recovered to 3.1% in June 2020; these were below 2019 screening rates of 4.2% for April and 3.9% for June. Differences in screening rates by payer type were also observed. Patients with commercial insurance had higher screening rates compared with those covered by Medicare FFS and managed Medicaid. Our principal finding shows that mean breast cancer screening rates decreased in April 2020 across all payers, but recovery to prepandemic screening levels has occurred more slowly among certain racial and ethnic minority groups. Differences in recovery rates by payer type highlight a strong relationship between income level and screening utilization.

Abstract B25: Empowering Latinas to obtain breast cancer screenings: Comparing intervention effects, part 1

Abstract Purpose: Latinas suffer disproportionately from breast cancer relative to non-Latina Whites (NLWs), partially due to lower guideline-concordant screening. In response, a significant body of work first sought to characterize disparities and associated determinants. Second, multiple approaches were developed to address this disparity, including community health worker (CHW)-driven education to the target population and empowerment interventions, wherein CHWs train a subset of the population to disseminate education to other members of the target population and mobilize in the context of health. The next logical step is to compare the relative effectiveness of interventions for future large-scaled implementation. Objective: We report emerging evidence from an ongoing, quasi-experimental trial that compares the effects of education and empowerment approaches on Latinas who are nonadherent to US Preventive Services Task Force breast cancer screening guidelines. Methods: The setting for this trial is in two Latino, lower-income communities in Chicago (Pilsen/Little Village, East Side/Chicago). Women are recruited via two community-based organizations (The Resurrection Project, Centro Comunitario Juan Diego) and snowball sampling. Eligibility criteria include: 1) age of 50-74; 2) lack of screening within past 2 years; 3) no previous breast cancer diagnosis; and 4) no prior health volunteerism experience. After screening and providing informed consent, women are assigned to a cohort (6-10 sessions) and participate in a three-week intervention (three 2-hour sessions). The education intervention is administered in East Side/Chicago and the empowerment intervention is administered in Pilsen/South Chicago to avoid contamination effects. The education intervention consists of a session focused on breast cancer and methods of early detection, a session focused on diet as a method of prevention, and a session focused on physical activity as a method of prevention. The empowerment intervention consists of a session focused on breast cancer and methods of early detection, a session focused on one-on-one conversations with family and friends about breast cancer, and a session focused on health-related volunteerism. For women who wish to obtain mammography (from either arm), study team provides navigation to free/low-cost services and tracks participants throughout the continuum of care. Three questionnaires are given: baseline (before Session #1), postintervention (after Session #3), and a follow-up (6 months after Session #3). Receipt of screening is confirmed by study and medical records for women who have completed HIPAA forms. Participants are compensated $80 for their participation. As well, during and after the intervention, participants may refer other nonadherent Latinas to the study for a small incentive ($15). Results: Our current sample is 37 women (20 education; 17 empowerment). The average age was 61.62 years old (SD = 6.02). Approximately 89% of participants were born in Mexico and approximately 81% had less than a high school education. The median annual household income was <$15,000. A greater proportion of empowerment participants have scheduled a mammogram relative to education participants (20% vs. 76%; p=.001). Relative to education participants, a greater proportion of empowerment participants have discussed breast cancer with other nonadherent Latinas and referred them to the study (5% vs 33%; p = .05). Discussion: Preliminary findings suggest the empowerment approach may be more effective in promoting breast cancer screening among nonadherent Latinas and disseminating information to their peers. Limitations concern generalizability due to a non-probability based sample and limited ability for causal inferences due to a lack of randomization. Next steps include comparing receipt of screening and characterizing diffusion of information throughout participants' social networks. Citation Format: Yamile Molina, Liliana G. San Miguel, Lizeth Tamayo, Sylvia Gonzalez, Rosa de la Torre, Kryztal Peña, Araceli Lucio, Oliva Hernandez, Juanita Arroyo, Maria C. Medina, Nora Coronado. Empowering Latinas to obtain breast cancer screenings: Comparing intervention effects, part 1 [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B25.

Screening Mammography for Women in Their 40s: The Potential Impact of the American Cancer Society and U.S. Preventive Services Task Force Breast Cancer Screening Recommendations.

The purpose of this study was to review screening mammograms obtained in one practice with the primary endpoint of determining the rate of detection of breast cancer and associated prognostic features in women 40-44 and 45-49 years old. The retrospective cohort study included women in their 40s with breast cancer detected at screening from June 2014 through May 2016. The focus was on cancer detection rate, pathologic findings, and risk factors. A total of 32,762 screens were performed, and 808 biopsies were recommended. These biopsies yielded 224 breast cancers (cancer detection rate, 6.84 per 1000 screens). Women 40-49 years old had 18.8% of cancers detected; 50-59 years, 21.8%; 60-69 years, 32.6%; and 70-79 years, 21.4%. Among the 40- to 49-year-old women, women 40-44 years old underwent 5481 (16.7%) screens, had 132 biopsies recommended, and had 20 breast cancers detected (cancer detection rate, 3.6/1000). Women 45-49 years old underwent 5319 (16.2%) screens, had 108 biopsies recommended, and had 22 breast cancers detected (cancer detection rate, 4.1/1000). Thus, women 40-44 years old had 8.9% and women 45-49 years old had 9.8% of all screen-detected breast cancers. Of these only a small percentage of women with detected cancers had a first-degree relative with breast cancer (40-44 years, 15%; 45-49 years, 32%) or a BRCA mutation (40-44 years, 5%; 45-49 years, 5%), and over 60% of the cancers were invasive. Women 40-49 years old had 18.8% of all screen-detected breast cancers. The two cohorts (40-44 and 45-49 years old) had similar incidences of screen-detected breast cancer (8.9%, 9.8%) and cancer detection rates within performance benchmark standards, supporting a similar recommendation for both cohorts and the American College of Radiology recommendation of annual screening mammography starting at age 40.

Mammography rates after the 2009 revision to the United States Preventive Services Task Force breast cancer screening recommendation.

In 2009, the United States Preventive Services Task Force (USPSTF) recommended against routine mammography screening for women aged 40-49years. This revised recommendation was widely criticized and has sparked off intense debate. The objectives of this study are to examine the impact of the revised recommendation on the proportion of women receiving mammograms and how the effect varied by age. We identified women who had continuous health insurance coverage and who did not have breast cancer between 2008 and 2011 in the Truven Health MarketScan Commercial Claims Databases using mammogram procedure codes. Using women aged 50-59years as a control group, we used a differences-in-differences approach to estimate the impact of the revised recommendation on the proportion of women ages 40-49years who received at least one mammogram. We also compared the age-specific changes in the proportion of women ages 35-59years who were screened before and after the release of the revised recommendation. The proportion of women screened among the 40-49 and 50-59 age groups were 58.5 and 62.5%, respectively, between 2008 and 2009, and 56.9 and 62.0%, respectively, between 2010 and 2011. After 2009, the proportion of women screened declined by 1.2 percentage point among women aged 40-49years (P<0.01). The proportion of women screened decreased for all ages, and decreases were larger among women closer to the 40-year threshold. The 2009 USPSTF breast cancer recommendation was followed by a small reduction in the proportion of insured women aged 40-49years who were screened. Reductions were larger among women at the younger end of the age range, who presumably had less prior experience with mammography than women nearing 50.

Screening Mammography Use Among Older Women Before and After the 2009 U.S. Preventive Services Task Force Recommendations.

It is uncertain how changes in the U.S. Preventive Services Task Force breast cancer screening recommendations (from annual to biennial mammography screening in women aged 50-74 and grading the evidence as insufficient for screening in women aged 75 and older) have affected mammography use among Medicare beneficiaries. Cohort study of 12 million Medicare fee-for-service women aged 65-74 and 75 and older to measure changes in 3-year screening use, 2007-2009 (before) and 2010-2012 (after), defined by two measures-proportion screened and frequency of screening by age, race/ethnicity, and hospital referral region. Fewer women were screened, but with similar frequency after 2009 for both age groups (after vs. before: age 65-74: 60.1% vs. 60.8% screened, 2.1 vs. 2.1 mammograms per screened woman; age 75 and older: 31.7% vs. 33.6% screened, 1.9 vs. 1.9 mammograms per screened woman; all p < 0.05). Black women were the only subgroup with an increase in screening use, and for both age groups (after vs. before: age 65-74: 55.4% vs. 54.0% screened and 2.0 vs. 1.9 mammograms per screened woman; age 75 and older: 28.5% vs. 27.9% screened and 1.8 vs. 1.8 mammograms per screened woman; all p < 0.05). Regional change patterns in screening were more similar between age groups (Pearson correlation r = 0.781 for proportion screened; r = 0.840 for frequency of screening) than between black versus nonblack women (Pearson correlation r = 0.221 for proportion screened; r = 0.212 for frequency of screening). Changes in screening mammography use for Medicare women are not fully aligned with the 2009 recommendations.

Abstract P6-02-08: Breast cancer screening in the precision medicine era

Abstract We are entering the era of precision medicine in which cancer screening, prevention and treatment will be tailored to each individual. The progress made in this field is due, in part, to advances in our understanding of cancer risk and tumor biology. The challenge before us is to harness this knowledge and apply it in the clinical setting. Breast cancer screening provides an excellent opportunity to test the value of precision medicine in the real world. In this report we describe the process of designing a model of personalized breast cancer screening. Methods Risk factors were selected that have the greatest impact, have been validated and can be measured across a population. A risk model was selected that is highly calibrated, has been validated in a large screening cohort and is easy to apply in a large population of women. An expert committee was convened that set risk thresholds for stratifying women into groups that will be recommended to undergo biennial, annual or every six month screening. Risk thresholds and screening schedules are in accordance with the United States Preventive Services Task Force breast cancer screening recommendations. Results Risk factors: Age, race/ethnicity, personal history of breast biopsies and benign breast disease, family history, breast density and breast cancer-associated genetic mutations and single nucleotide polymorphisms (SNPs) were chosen as the risk factors that will be used to determine breast cancer risk. Risk model: The Breast Cancer Surveillance Consortium risk model will be used to calculate a woman's 5-year risk and will be modified by a polygenic risk score based on 81 SNPs. Risk thresholds: Women will be recommended to undergo biennial screening mammography when they reach the age of 50 or have the risk of an average 50 year-old woman (1.3% 5-year risk). Women will be advised to undergo annual screening if they are at increased risk of developing an interval cancer (women in their forties with extremely dense breasts and women at increased risk of developing estrogen receptor negative breast cancer based on their SNPs). Women will be recommended to undergo annual mammography and annual MRI if they are found to be gene mutation positive, have the risk of a BRCA1 mutation carrier (6% 5-year risk) or have a history of mantle radiation. Discussion Selecting the appropriate risk factors and risk model and determining risk thresholds are key components of designing a personalized breast cancer screening model. Personalized screening may be the way forward, but this can only be determined within the setting of a randomized controlled trial. We will conduct such a trial to determine if personalized screening is as safe as, less morbid than, more preferred by women than and enables prevention when compared to annual screening. The WISDOM (Women Informed to Screen Depending on Measures of risk) study will compare risk-based screening to annual screening within the Athena Breast Health Network with support from the Patient-Centered Outcomes Research Institute. Our intent is that this trial will provide us with the data that we need to determine the safest and most effective way to screen women for breast cancer in the era of precision medicine. Citation Format: Thompson CK, Fiscalini AS, Donnellan P, Kaplan CP, Madlensky L, Eklund M, Ziv E, van't Veer LJ, Tice JA, Esserman LJ. Breast cancer screening in the precision medicine era. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-02-08.

The Effect of the 2009 U.S. Preventive Services Task Force Breast Cancer Screening Recommendations on Mammography Rates.

To examine the effect of a change in U.S. Preventive Services Task Force (USPSTF) screening guidelines on mammography rates in the United States. In 2010, the year following the change in guidelines, 12-month mammography prevalence among women aged 40-49 years fell by 2.09 percentage points (95 percent confidence interval [CI]: -2.87 to -1.31) from 54.63 percent in 2008. For women aged 50-74 years, and aged 75 years and older, 12-month screening rates were 2.21 (95 percent CI: -2.65 to -1.77) and 3.60 (95 percent CI: -4.48 to -2.70) percentage points lower than those in 2008. In 2012, for women aged 40-49 years, 12-month prevalence fell to 52.51 percent, a decline of 2.12 percentage points (95 percent CI: -2.79 to -1.32) relative to screening rates prior the USPSTF announcement. For women aged 50-74 years and aged 75 years and older screening rates were 2.45 (95 percent CI: -2.96 to -2.07) and 5.71 (95 percent CI: -6.61 to -4.81) percentage points lower, respectively, in 2012 than in 2008. This study demonstrates an immediate and lasting reduction in the rates of breast cancer screening among women of all age groups after the 2009 revision of screening guidelines by the USPSTF.

Mammography Use and Physician Recommendation After the 2009 U.S. Preventive Services Task Force Breast Cancer Screening Recommendations

In 2009, the U.S. Preventive Services Task Force (USPSTF) no longer recommended routine mammography for women aged 40-49 and ≥75 years (younger and older women, respectively). Whether mammography usage and physician recommendation among younger and older women changed in response to these recommendations is unclear. Cross-sectional data from women aged ≥40 years in the 2008 and 2013 National Health Interview Surveys were used (n=4,942 younger and 3,047 older women) and were analyzed in 2015. Changes between 2008 and 2013 in self-reports about having undergone mammography in the past 2 years and physician recommendation for mammography were expressed as adjusted prevalence difference (PD) and 95% CI. Overall, adjusted prevalence of mammography among younger women was similar in 2008 (62.2%) and 2013 (58.5%) (p=0.05), but significantly declined in high-income (PD=-6.1%, 95% CI=-11.2, -1.0); non-Hispanic white (PD=-5.5%, 95% CI=-10.2, -0.8); and privately insured (PD=-5.7%, 95% CI=-9.8, -1.6) younger women. For older women, there was no change in adjusted mammography prevalence overall (2008, 56.2%; 2013, 54.2%; p=0.473) or by SES. Physician mammography recommendation declined in younger (PD=-5.0%, 95% CI=-8.7, -1.3) and older (PD=-5.8%, 95% CI=-10.5, -1.1) women. Four years after publication of USPSTF mammography recommendations, mammography prevalence for younger and older women did not significantly decrease except for higher-SES younger women. The significant decrease in physician recommendation of mammography in younger and older women may reflect a change in practice patterns by some physicians in response to USPSTF recommendations.

Impact of the 2009 US Preventive Services Task Force guidelines on screening mammography rates on women in their 40s.

BackgroundThe 2009 US Preventive Services Task Force breast cancer screening update recommended against routine screening mammography for women aged 40–49; confusion and release of conflicting guidelines followed. We examined the impact of the USPSTF update on population-level screening mammography rates in women ages 40–49.Methods and FindingsWe conducted a retrospective, interrupted time-series analysis using a nationally representative, privately-insured population from 1/1/2006-12/31/2011. Women ages 40–64 enrolled for ≥1 month were included. The primary outcome was receipt of screening mammography, identified using administrative claims-based algorithms. Time-series regression models were estimated to determine the effect of the guideline change on screening mammography rates. 5.5 million women ages 40–64 were included. A 1.8 per 1,000 women (p = 0.003) decrease in monthly screening mammography rates for 40–49 year-old women was observed two months following the guideline change; no initial effect was seen for 50–64 year-old women. However, two years following the guideline change, a slight increase in screening mammography rates above expected was observed in both age groups.ConclusionsWe detected a modest initial drop in screening mammography rates in women ages 40–49 immediately after the 2009 USPSTF guideline followed by an increase in screening rates. Unfavorable public reactions and release of conflicting statements may have tempered the initial impact. Renewal of the screening debate may have brought mammography to the forefront of women's minds, contributing to the observed increase in mammography rates two years after the guideline change. This pattern is unlikely to reflect informed choice and underscores the need for improved translation of evidence-based care and guidelines into practice.

Mammography rates after the 2009 US Preventive Services Task Force breast cancer screening recommendation

ObjectiveTo measure the impact of the 2009 US Preventive Services Task Force (USPSTF) breast cancer screening recommendation, which recommended against routine screening for women aged 40 to 49 and stated that there was “insufficient evidence” to recommend screening for women aged 75 and older, on mammography rates. MethodsSelf-reported mammography rates were calculated using the 2006–2010 Medical Expenditure Panel Surveys (n=29,857). The paper reports mammography rates by age group (40 to 49, 50 to 74, and 75 and older), adjusted for age, race/ethnicity, socioeconomic status, and region. The study was performed at Emory University in Atlanta, Georgia, USA in 2012. ResultsDifferences in mammography rates between 2010 and earlier years were not significant. Among women aged 40–49, biennial mammography rates declined by −0.5 percentage points between 2006 to 2009 and 2010 (95% confidence interval [CI]: −3.0 to 1.9; p=0.67). Among women aged 50–74, rates declined by −0.07 percentage points (95% CI: −1.8 to 1.7; p=0.93). Among women aged 75years and older, rates declined by −0.1 percentage points (95% CI: −4.2 to 3.9; p=0.94). ConclusionThe revision to the USPSTF breast cancer screening recommendation did not affect screening patterns.

Physician knowledge of and adherence to the revised breast cancer screening guidelines by the United States Preventive Services Task Force

We sought to assess knowledge and adherence to the revised US Preventive Services Task Force breast cancer screening guidelines among gynecologic care providers. This was a cross-sectional descriptive study based on a survey conducted among gynecologic care providers. Forty providers completed the survey (80%). In response to the statement "The current recommended age to initiate breast cancer screening is … .," 48.7% of providers responded in accordance with revised guidelines. For the statement "Women between the age of 50 and 74 years old are recommended to have screening mammography," 46.2% of respondents answered in accordance. In response to the statement "The United States Preventative Services Task Force recommends teaching breast self-examination," 71.8% of providers responded in accordance. A total of 37 respondents (92.5%) stated that they were aware of the revised guidelines, but 17 (42.4%) stated that they were applicable to their patient population. Knowledge of the revised guidelines appeared to be relatively low in our provider sample.