New ACR Guidelines Say All Women Should Have Breast Cancer Risk Assessment by Age 25
All women, especially Black and Ashkenazi Jewish women who are considered high risk, should have a breast cancer risk assessment by age 25 to determine if they need to start regular screening earlier than age 40, according to new guidelines from the American College of Radiology (ACR).
The guidelines were published online on May 3, 2023, by the Journal of the American College of Radiology. Read “Breast Cancer Screening for Women at Higher-than-Average Risk: Updated Recommendations from the ACR.”
Breast cancer in Black and Ashkenazi Jewish women
Black women are less likely than white women to be diagnosed with breast cancer. Still, for the last four decades, we’ve known that Black women are about 40% more likely to die from breast cancer than white women. Studies have suggested that a number of factors contribute to this disparity, including structural racism in the healthcare system and cancer tumor biology.
Because Black women have higher breast cancer mortality rates than white women, in 2018 the ACR and the Society of Breast Imaging recommended that Black women be added to groups considered at high risk of breast cancer. This was the first time Black women were classified as a high-risk group.
Ashkenazi Jewish women have a much higher-than-average risk of having a founder mutation in the BRCA1 and BRCA2 genes — about a 1 in 40 risk. This is part of the reason why Ashkenazi Jewish women have a much higher-than-average risk of breast cancer.
A founder mutation is a specific gene mutation in a population that was founded by a small group of ancestors that were geographically or culturally isolated. Because the population was isolated, the rate of founder mutations in descendants is much higher than it would be if the population were larger and intermingling with more genetically diverse people.
Mutations in the BRCA1 and BRCA2 genes are two of the most well-known mutations linked to a higher risk of breast cancer. The average woman in the United States has about a one in eight, or about 12%, risk of developing breast cancer in her lifetime. Women who have a BRCA1 or BRCA2 mutation (or both) can have up to a 72% risk of being diagnosed with breast cancer during their lifetimes. Breast cancers associated with a BRCA1 or BRCA2 mutation tend to develop in younger women and occur more often in both breasts than cancers in women without these genetic mutations.
Confusion around breast cancer screening recommendations
From 2000 to 2015, a number of large studies ignited debate over when people should begin having screening mammograms.
Public health experts agree that breast imaging saves lives, but question the value of screening mammograms. These experts say that for each breast cancer death screening mammograms prevent, three to four women are overdiagnosed.
Overdiagnosis means that a screening mammogram finds:
a suspicious area that would have been eventually diagnosed as cancer by other means without affecting the prognosis
a suspicious area that never would have been diagnosed as cancer if it had been found or treated
False-positive results from screening mammograms also have helped fuel the debate about the value of breast cancer screening and when it should start. When a mammogram shows an abnormal area that looks like cancer but turns out to be normal, it’s called a false positive. Ultimately the news is good: no breast cancer. But the suspicious area usually requires follow-up with more than one doctor, extra tests, and extra procedures — including a possible biopsy. There are psychological, physical, and economic costs that come with a false positive.
Because of the continued debate, a number of organizations revised their breast cancer screening recommendations for women at average risk of breast cancer. Some organizations recommend starting screening mammograms at age 50, and others recommend starting at age 40. At the same time, some organizations recommend having a mammogram each year, and others recommend having a mammogram every other year. As a result, there is confusion about when you should start having screening mammograms, as well as how often you should have them.
Aiming to clarify when people should start getting mammograms, the National Comprehensive Cancer Network (NCCN) released guidelines for breast cancer screening and diagnosis in 2022 saying that everyone who has breasts age 40 and older at average risk of breast cancer should have an annual mammogram.
All these guidelines are mainly aimed at people at average risk.
ACR guideline recommendations
The new ACR guidelines are for people who have a higher-than-average risk of breast cancer:
All women, particularly Black and Ashkenazi Jewish women, should have a breast cancer risk assessment by age 25 to decide if regular screening should begin earlier than age 40.
Women with a higher-than-average risk of breast cancer because of a genetic mutation, such as a BRCA1 or BRCA2 mutation, and women who have a lifetime risk of breast cancer that is 20% or higher should have an annual digital mammogram starting at age 30.
Women with a genetic mutation can start annual mammograms at age 40 if they start annual breast MRI screening at age 25.
Women who received radiation to the chest before age 30 should start breast cancer screening at age 25, or eight years after receiving radiation, whichever is later.
Women who were diagnosed with breast cancer or certain benign breast conditions before age 40 should start annual mammograms at the time of diagnosis.
Women with a higher-than-average risk of breast cancer because of a genetic mutation, such as a BRCA1 or BRCA2 mutation; women who have a lifetime risk of breast cancer that is 20% or higher; and women who received radiation to the chest at a young age should have an annual breast MRI starting between the ages of 25 and 30.
Women diagnosed with breast cancer before age 50 or women who have a personal history of breast cancer and have dense breasts should start annual breast MRI screening at the time of diagnosis. Other women with a personal history of breast cancer should strongly consider supplemental screening with breast MRI, especially if they have other risk factors.
Women who have dense breasts who want to have supplemental screening should have a breast MRI.
Women who have been diagnosed with lobular carcinoma in situ or atypia (the cells look abnormal, but are not cancerous yet) should consider supplemental screening with breast MRI, especially if they have other risk factors.
Women with a higher-than-average risk of breast cancer who would qualify for breast MRI screening but can’t have that procedure could consider supplemental screening with ultrasound.
What this means for you
These new ACR guidelines make a recommendation that applies to everyone with breasts, regardless of breast cancer risk: to have a breast cancer risk assessment by age 25. You can do this with your doctor by discussing the following points:
family history of breast or other related cancers (ovarian, melanoma)
any test results for gene mutations linked to higher breast cancer risk
results of past breast biopsies, even if they were benign
personal history of radiation treatment to the face, chest, or both before age 30
breast density
weight
level of physical activity
any use of post-menopausal combined hormone replacement therapy (HRT)
alcohol consumption, if you regularly drink more than three alcoholic beverages a week
the amount of processed food and trans fats you eat
your smoking history
whether or not you have carried a pregnancy to term or have breastfed
If you determine that you have a higher-than-average risk of developing breast cancer, talk to your doctor about when you should start annual mammograms and whether you need supplemental screening with MRI or ultrasound.
Learn more about breast cancer screening.
— Last updated on June 20, 2023 at 3:12 PM