The idea of risk-based mammography screening is back with the publication of a new study in JAMA Network Open claiming that some risk-based strategies averted more breast cancer deaths with fewer false positives than age-based criteria. But like a previous paper on risk-based screening, the new findings raise concerns.
The idea behind risk-based screening is to focus healthcare resources on the people who need them most while sparing low-risk individuals from unnecessary medical interventions.
- But risk-based breast cancer screening needs more clinical validation before it can be adopted broadly. This was tried with the WISDOM study, but researchers found no statistically significant difference in biopsy rates and only a modest reduction in mammograms performed.
A slightly different tack was taken with the new study, which compared conventional age-based biennial screening to a package of risk-based approaches based on a patient’s five-year breast cancer risk as calculated by widely accepted techniques like the Gail model and BCSC calculator.
- Out of 50 risk-based strategies, nine averted more deaths than biennial age-based screening for women aged 40-74 (both were compared to no screening), and resulted in fewer false-positive recalls.
One such strategy highlighted by the authors used no screening for younger low-risk women, biennial screening for average-risk women, and annual screening for intermediate- and high-risk women, with the following results…
- 6% more breast cancer deaths averted per 1k women versus conventional screening (7.2 vs. 6.8).
- 8% fewer false-positive recalls (1,257 vs. 1,365).
- While other risk-based strategies saw death reductions as high as 7.5 deaths per 1k women and false-positive reductions of 8-23%.
One key thing to note with the new study is its use of biennial screening as the control group, in line with current USPSTF recommendations for women aged 40-74.
- But many clinical organizations like ACR, ACOG, SBI, and NCCN recommend annual screening, and the new study’s findings may have been very different if compared to an annual model.
The Takeaway
This week’s findings are generally more supportive of risk-based screening than those of last year’s WISDOM study. But the new paper’s marginal improvement in cancer deaths averted might disappear when compared with annual age-based mammography. And like WISDOM, its use of clinical models for risk prediction may soon be obsolete given rapid developments in AI-based risk assessment.
