Tailoring Breast Cancer Screening Intervals by Breast Density and Risk for Women Aged 50 Years or Older: Collaborative Modeling of Screening Outcomes

Abstract

Background: Biennial screening is generally recommended for average-risk women aged 50 to 74 years, but tailored screening may provide greater benefits.

Objective: To estimate outcomes for various screening intervals after age 50 years based on breast density and risk for breast cancer.

Design: Collaborative simulation modeling using national incidence, breast density, and screening performance data.

Setting: United States.

Patients: Women aged 50 years or older with various combinations of breast density and relative risk (RR) of 1.0, 1.3, 2.0, or 4.0.

Intervention: Annual, biennial, or triennial digital mammography screening from ages 50 to 74 years (vs. no screening) and ages 65 to 74 years (vs. biennial digital mammography from ages 50 to 64 years).

Measurements: Lifetime breast cancer deaths, life expectancy and quality-adjusted life-years (QALYs), false-positive mammograms, benign biopsy results, overdiagnosis, cost-effectiveness, and ratio of false-positive results to breast cancer deaths averted.

Results: Screening benefits and overdiagnosis increase with breast density and RR. False-positive mammograms and benign results on biopsy decrease with increasing risk. Among women with fatty breasts or scattered fibroglandular density and an RR of 1.0 or 1.3, breast cancer deaths averted were similar for triennial versus biennial screening for both age groups (50 to 74 years, median of 3.4 to 5.1 vs. 4.1 to 6.5 deaths averted; 65 to 74 years, median of 1.5 to 2.1 vs. 1.8 to 2.6 deaths averted). Breast cancer deaths averted increased with annual versus biennial screening for women aged 50 to 74 years at all levels of breast density and an RR of 4.0, and those aged 65 to 74 years with heterogeneously or extremely dense breasts and an RR of 4.0. However, harms were almost 2-fold higher. Triennial screening for the average-risk subgroup and annual screening for the highest-risk subgroup cost less than $100 000 per QALY gained.

Limitation: Models did not consider women younger than 50 years, those with an RR less than 1, or other imaging methods.

Conclusion: Average-risk women with low breast density undergoing triennial screening and higher-risk women with high breast density receiving annual screening will maintain a similar or better balance of benefits and harms than average-risk women receiving biennial screening.

Primary funding source: National Cancer Institute.

Figure 1

False-positives mammograms per breast cancer death averted for women (A) aged 50–74 and (B) aged 65–74 according to screening frequency and risk level (relative risk group, breast density) using an exemplar model (Model E). Values for all screening frequencies compared to the scenario with no mammography screening. Values for ages 65–74 assume all women received biennial screening during ages 50–64. Dashed lines show this value for women with average density and average risk receiving biennial screening (147.7 for ages 50–74 and 105.8 for ages 65–74). Having fewer false-positives per death averted than this level, i.e., a value below the dashed line, would be more favorable.