Breast Cancer Screening and Mortality Rates in Younger Women

A new study published in Radiology draws attention and concern to mortality rates from breast cancer among women who were younger than 40 at the time of diagnosis. Mortality rates for women of all ages in the United States dropped annually between 1989 and 2010, but then steadied for younger women. Experts are worrying that mortality rates for this group will rise in the next few years as some women, currently diagnosed and under treatment, do not do well.

There is widespread concern about the increasing incidence of breast cancer in young women.

The National Center for Health Statistics reports that breast cancer mortality rates decreased by 1.5% to 3.4% each year for women of all ages between 1989 and 2010. After 2010, the incidence for women aged 40-79 continued to decrease from 1.2% to 2.2% per year. However, after 2010, the rates increased 2.8% per year for women 20-29 and 0.3% for women 30-39. The incidence of de novo breast cancer (those that were metastatic at the time of diagnosis) increased by more than 4% each year after 2000 for women who were 20-39.

Why is this happening? No one really knows, but the best guess is that it is related to less frequent mammograms/screening in younger women. Generally, annual mammograms are not recommended for women under 40. Women who carry a genetic mutation (BRCA1 or BRCA2) or have a strong family history are advised to start screening at 35. Women whose mothers had breast cancer are generally told to have a first mammogram when they are ten years younger than their mother was at the time of her diagnosis. The American Cancer Society suggests that:

• Women 40-44 should have the option of annual mammograms
• Women 45-54 should have annual mammograms
• Women 55 and older can reduce their screening mammograms to every two years or stick with annual tests
• Women should continue with annual mammograms as long as their anticipated life expectancy is ten years or more.

There is also the recommendation that women who are at high risk should have a first mammogram by age 35. Here is where it gets interesting. Everyone agrees that high risk includes women with a gene mutation or strong family history. The family history includes having a first degree relative with breast cancer, a relative who had breast cancer in both breasts, or several more distant family members who have had breast cancer. Increasingly, that designation is also being applied to other groups: women who have dense breasts, have had radiation exposure to the chest, or are African American or of Ashkenazi Jewish descent. We know that dense breasts make it more difficult to correctly interpret a mammogram. The usual comment is that it’s like looking for a polar bear in a snowstorm. What you may not already know is that the mere fact of having dense breasts is a risk factor for breast cancer.

The American College of Radiology recommends that African American women should have a risk assessment at age 30 to determine when to begin annual mammograms. As opposed to the regular population, young Ashkenazi Jewish women have a breast cancer incidence of one in 40 as opposed to one in 400. Again, this means that you should speak with your doctor about your individual situation and family history.

Breast cancer can be a devastating diagnosis for a woman of any age. For obvious reasons, it is even worse for young women who may find all of their life’s plans disrupted or shattered. Doctors no longer believe that young women with breast cancer have poorer prognoses than older women; the understanding now is that stage for stage, the prognosis is the same whatever the woman’s age. However, there is widespread concern about the increasing incidence of breast cancer in young women and the likelihood that many will be diagnosed at later stages and do less well because of less frequent screening.

Most women who have had breast cancer strongly endorse the need for annual mammograms for women of all ages. There are expressed public health concerns about unnecessary biopsies and stress and cost, but most women would rather experience a few worried weeks than discover later that they have a more advanced breast cancer. Early diagnosis is not an absolute promise of a good and healthy outcome, but it is certainly an important factor.