Screening Mammography and the Impact of Breast Imaging in Lowering Mortality Rates

Debra L. Monticciolo, MD, FACR, Chair, Screening Leadership Group and Communications, ACR Commission on Breast Imaging, was a guest columnist for Alan H. Matsumoto, MD, MA, FACR, in this "From the Chair of the Board of Chancellors" column.

This is part one of this month’s Board of Chancellors column on early detection through screening. Check out what Ben Wandtke, MD, MS, Vice Chair of the ACR Commission on Quality and Safety, Chair of the Recommendations Follow-Up Improvement Collaborative within the ACR Learning Network, has to say in part two, which focuses on lung cancer.

Early detection of breast cancer by screening mammography has had a significant and lasting impact on women in the United States. Widespread mammography use developed here in the 1980s, and positive results began to appear a few short years later. The breast cancer death rate — which had been unchanged for decades to that point — began to fall for the first time in 1990. Between 1990 and 2025, the U.S. breast cancer death rate has fallen by 43%.

While this is good news overall, recent data analysis shows that breast cancer mortality rates have stopped declining for women under age 40 and over age 74 years. This is at least partially due to another worrisome trend. Rates of distant-stage (stage IV) breast cancer at the time of diagnosis (which has the highest death rate) increased significantly between 2004 and 2021 for U.S. women overall and for age groups 20–39 years, 40–74 years and 75 years and older. Clearly, our work is not done.

Women have benefited both from screening mammography and treatment advances. However, it is clear from the extensive work done in Sweden that early detection is key. In their landmark study with 58 years of follow-up and more than 2 million examinations, Tabár and colleagues showed that screened women had 60% lower mortality at 10 years follow-up and 47% lower mortality at 20 years follow-up than unscreened women — with both groups having the same available treatments for breast cancer. Duffy, Tabár et al. expanded their methodology to cover 549,091 women in nine counties in Sweden (30% of Swedish screening-eligible women). Again, they showed that when using the same available treatments, screened women had 41% lower mortality at 10 years of follow-up and a 25% lower risk of advanced breast cancer than unscreened women. The key to success is not treatment alone. To be successful in decreasing breast cancer deaths, we need to find lesions early through screening.

 

There is no doubt, from a scientific standpoint, that ACR’s recommendation of annual screening beginning at age 40 saves more lives than either the U.S. Preventive Services Task Force (USPSTF) or the American Cancer Society’s recommendations. The USPSTF currently recommends biennial screening beginning at age 40 and ending at age 74. The difference between our two recommendations is stark. Using tomosynthesis, the current USPSTF recommendations would result in a 30% mortality reduction in breast cancer while the ACR recommendation would result in a greater than 42% mortality reduction. Also worth noting: The Cancer Intervention and Surveillance Modeling Network limits modeling beyond age 79 and ACR does not recommend an upper limit based on age. This difference translates to the unnecessary loss of thousands of women’s lives when USPSTF recommendations are followed.

The USPSTF limits its screening recommendations to reduce the risks of screening — which the USPSTF calls “harms.” The agency points to increased recalls and unnecessary (or benign) biopsies with annual screening beginning at age 40 and extending beyond age 74 years versus biennial screening for only a limited time period (40–74 years of age). This is just simple arithmetic — doing more screening and screening more frequently over more years will result in more overall recalls and biopsies. However, it is important to consider this from the woman’s perspective. “What can I expect, me personally, if I undergo screening?” That is a fair and common question. In fact, on a per-examination basis, recalls and benign biopsies are lowest with annual screening beginning at age 40 and extending beyond age 74. The risk of recall with annual screening age 40–79 is 6.5% and the risk of benign biopsy is 0.88%, the lowest of any screening scenario we modeled. For any scenario, the risk of recall is low (<10%), as is the risk of having a benign biopsy (<1.33%).

Dissuading women from screening to spare them non-lethal, manageable risks is folly. The USPSTF wants to weigh benefits and harms for women and give them the answer. These decisions should be made by women, not for them. Let’s give them the correct information and let them decide. Women can maximize their chance at breast cancer mortality reduction with annual screening beginning at age 40 and continuing as long as they are in good health. The risks are low, and none are life-threatening — unlike advanced breast cancer. We must put the health and lives of women first.

Read a Q&A with ACR Commission on Breast Imaging Chair Stamatia “Toula” Destounis, MD, FACR, FSBI, FAIUM, to get her thoughts on the many moving parts of ensuring early detection.