Dr. Michael Barry

Chair, U.S. Preventive Services Task Force

5600 Fishers Lane

Rockville, MD 20857

Dear Dr. Barry,

As an organization focused on ensuring all women have access to affordable, comprehensive preventive care and screenings, the Alliance for Women’s Health & Prevention (AWHP) commends the U.S. Preventive Services Task Force (USPSTF) for proposing an update to its breast cancer screening guidelines and ensuring insurance coverage for mammograms starting at age 40.

These proposed changes could not have come at a more urgent time. Breast cancer is the second most common cancer among women in the U.S. and makes up 30% of all new female cancer diagnoses each year. Given that approximately 1 in 8 women will be diagnosed with breast cancer in their lifetime, lessening the disease’s impact and burden is imperative, and will require a cross-coordinated effort by healthcare leaders, healthcare providers, and policymakers who all agree that mammograms starting at age 40 for all women is the best and healthiest way forward. AWHP is glad to count the Task Force among those partners.

Breast Cancer Disparities

These new draft guidelines reflect an important step forward in addressing racial disparities in breast cancer’s devastating impact.

• Black women and Hispanic women have lower breast cancer survival rates than white women. American Indian and Alaska Native women also have higher breast cancer mortality rates than white women, despite having lower incidence.
• Black women younger than age 50 have a breast cancer death rate that is twice as high as white women of the same age.
• Black women are less likely to receive an early-stage diagnosis than white women and are disproportionately affected by more aggressive subtypes of the disease, including triple-negative breast cancer (TNBC).
• Breast cancer is the leading cause of cancer deaths for Hispanic women living in the U.S.
• American Indian/Alaska Native women were 17% less likely to be diagnosed with breast cancer than white women but 4% more likely to die from the disease.
• One in 40 Ashkenazi Jews carries the BRCA genetic mutation, which raises a person’s risk for getting breast cancer at a young age, and also for getting ovarian and other cancers. Ashkenazi Jewish women are also at higher risk for breast cancer at a young age.
• Women living in rural areas experienced greater reduction in screenings compared with their urban counterparts.
• Rural women face challenges with scarcity of resources and physicians and long distances to medical facilities when it comes to screening mammography.
• Rural women had the largest proportion of women diagnosed with distant breast cancer compared with women from small urban or large urban areas.

The Path Forward

While AWHP welcomes the long-awaited shift to begin mammography at age 40 for all women, we are deeply disappointed that the draft guidelines do not include recommendations for annual screenings, for women with dense breast tissue, and for women over the age of 75.

Annual breast cancer screening is critical and must be recommended. Annual screenings underscore the role that early detection plays in the fight against breast cancer and for long-term survival when diagnosed. According to the American Cancer Society, when breast cancer is detected early and is in the localized stage, the 5-year relative survival rate is 99%. Moreover, given that Black women are more likely to be diagnosed with breast cancer at later stages of the disease, including once it has metastasized, early detection through annual screening plays a key role in reducing health disparities. Performing breast exams earlier and more frequently is the best defense against cancer deaths.

Furthermore, we strongly recommend that the Task Force make specific recommendations for women with dense breast tissue that speak to the clinical benefit of 3D mammography over 2D. Women with dense breast tissue are at increased risk of developing breast cancer overall and for later-stage breast cancer diagnosis, but 3D image allows doctors to see beyond areas of density. Ignoring the additional risk that women with dense breast tissue face is irresponsible when research and data clearly demonstrate that this population is at greater risk of disease. We therefore must take a risk-adjusted approach to screening by ensuring that women with dense breasts have equitable access to additional, more comprehensive screening methods, which includes but is not limited to breast ultrasounds and MRIs.

We are also calling on the Task Force to include screening recommendations for women over the age of 75. Screenings remain critical for older women, given that breast cancer risk increases with age and the number of breast cancer cases in this age group is relatively high. The health of these women remains important, and should not be overlooked in the Task Force’s guidance.

AWHP is vehemently urging the USPSTF to include the following items in its final guidelines: annual breast cancer screenings for all women beginning at age 40, more vigilant recommendations for women with dense breast tissue, and continued mammography for women age 75 and older.

Equitable Coverage is Key

Because USPSTF guidelines inform insurance coverage of preventive care and services, they have a tremendous impact on the healthcare services that women ultimately seek. A survey commissioned by AWHP and conducted by Ipsos earlier this year reaffirmed the critical role of insurance coverage in keeping women healthy. The data shows that the number one barrier to preventive care is out-of-pocket costs and that women are less likely to receive screenings if they are not covered by insurance. Women want — and deserve — guidelines that prioritize affordability, early detection, patient-provider decision-making, and health equity impacts.

According to the survey:

• 91% of women say it’s important that guidelines prioritize ensuring that comprehensive preventive care and screening is affordable.
• 90% of women say it’s important that guidelines prioritize allowing for the earliest possible detection of disease through the most robust testing.
• 89% of women say it’s important that guidelines prioritize removing barriers to care and screenings.
• 87% of women say it’s important that guidelines prioritize ensuring there isn’t a negative impact on health equity.
• 84% of women say it’s important that guidelines prioritize considering the needs and lived experiences of all women by examining the potential impact of the recommendations on different races and populations.

The Time is Now

This is a pivotal moment in breast cancer care, and the stakes could not be higher. Since 1990, mammography has helped reduce breast cancer mortality in the U.S. by 40% — and the Task Force holds the ability to ensure that this number continues to rise, ultimately saving the lives of millions of women.

AWHP’s call is clear: we want annual breast cancer screenings for all women beginning at age 40; more vigilant recommendations for women with dense breast tissue, and continued mammography for women 75 and older. These recommendations will foster screening earlier, more frequently, and more comprehensively – undeniably resulting in more lives saved. We urge you to leverage your critical position to champion screening guidelines that support women’s well-being, happiness, and health.