A national health panel is recommending that women begin getting regular mammograms at age 40, rather than 50, citing an alarming increase in breast cancer in younger patients. Experts say the proposed guidance by the U.S. Preventive Services Task Force is particularly important for Hawaii, where the incidence of breast cancer is above the national average and mortality rates among Native Hawaiian women remain persistently high.
The previous guidelines to defer mammograms until 50 “were poorly suited for breast cancer detection in our population in Hawaii,” said Dr. Scott Grosskreutz, a diagnostic radiologist on Hawaii island, who said earlier screening should help save lives, particularly among younger women, who tend to have more aggressive breast cancers.
In Hawaii the rate of new cases of female breast cancer was 139.6 per 100,000 women per year, compared with the national rate of 129.6 cases, according to statistics from the University of Hawaii Cancer Center. Hawaii data also shows that invasive breast cancer incidence rates increased by about 1.7% annually from 2009 to 2018, similar to the national trend.
Hawaii’s higher breast cancer rates may in part be attributed to more women getting mammograms, but experts don’t think that is the sole reason.
“I think part of it is a better uptick of screening, but also there are underlying risk factors that are contributing to a real increase independent of screening effects,” said Brenda Hernandez, principal investigator for the UH Cancer Center’s Hawaii Tumor Registry. She said the higher incidence rate in Hawaii pertains to both younger and older women.
Native Hawaiian women have also been dying at significantly higher rates than other racial and ethnic groups. Their mortality rate stood at 24.9 per 100,000, compared with an average rate of 15.8 for all groups in Hawaii.
It’s not clear to what degree the higher mortality rates may be due to genetic factors, less screening, poorer access to health care, environmental exposures or lifestyle factors.
“That’s been one of the important questions for researchers here at the Cancer Center to address,” Hernandez said. “There are ongoing studies looking at just that.”
The higher death rates among Native Hawaiian women are similar to those of Black women, which helped drive the new guidance by the U.S. Preventive Services Task Force. Black women are 40% more likely to die from breast cancer than white women and have had higher rates of aggressive breast cancer at younger ages.
Research has also shown an earlier peak age of breast cancer incidence in Asian countries, according to a 2021 article in the Journal of Breast Imaging, which noted this was particularly pertinent to Hawaii, where Asians comprise 37% of the population.
The article also cites unpublished research from Straub Hospital on more than 22,000 women of Asian ancestry, which found that two-thirds of the women had dense breast tissue, a risk factor for breast cancer. In Hawaii, women of Japanese descent are the most likely to develop breast cancer before age 50, according to the research, though their outcomes are better than average, suggesting that the incidence is, at least in part, due to higher rates of screening.
Nationally, women have a 1-in-8 chance of developing breast cancer during their lifetime, and studies have shown that regular screening and early detection are important to reducing the likelihood of dying from it. In Hawaii an average of 155 women die from breast cancer annually, according to the UH Cancer Center data.
The new guidance from the U.S. Preventive Services Task Force, which still needs final approval, was supported by the American College of Radiology and the Hawaii Radiological Society.
It represents a reversal for the influential agency, which in 2009 issued guidance saying that routine mammograms for women at general risk shouldn’t start until 50. At the time, the task force said it was raising the age from 40 out of concern that earlier screenings could do more harm than good, leading to overtreatment and increasing anxiety among women, particularly those who need follow-up evaluations or biopsies, most of which turn out to be negative. About 80% of women who have a breast biopsy do not have cancer, according to the National Breast Cancer Foundation.
The change in guidance in 2009 was controversial and not supported by all doctors and health care groups, leaving women with conflicting guidance.
The American College of Radiology recommends annual screenings beginning at age 40 for women of average risk, and the American College of Obstetricians and Gynecologists recommends screenings every one to two years starting at age 40. The American Cancer Society, however, says that annual mammograms should begin at age 45.
In Hawaii, health care organizations have also adopted their own guidance. For example, Hawaii Pacific Health said that several years ago it adopted the recommendations of the American College of Radiology that all women undergo annual screenings beginning at age 40.
For women who are at higher risk because of their family history or a genetic mutation known to increase the risk of breast cancer, there is wide consensus that screening should be more aggressive, which could entail starting mammograms at a younger age or undergoing additional screening such as ultrasounds and magnetic resonance imaging, or MRI.
Access to care
Hawaii has some of the best breast cancer screening rates in the country. Some 76% of women 45 and older are up to date on their mammograms, compared with 67% of women nationally, according to 2020 data from the American Cancer Society. But that still means that many women in Hawaii are going without regular screenings.
Grosskreutz said the shortage of primary care doctors in Hawaii, particularly on the neighbor islands, is contributing to women forgoing mammograms or getting them late.
“In the absence of having enough health care providers, we get these women who are delaying care, looking for a health care provider that can order them a mammogram or get them tested for their (symptoms),” he said. “If they can’t find a health care provider, they often delay care for many months before they can find someone.”
He said that one option is for women to self-refer for a mammogram while waiting to get established with a doctor. He said women who are 40 or older can call any mammogram clinic and schedule a screening, but he said there are still challenges to access. Women who have possible symptoms of breast cancer could benefit from a diagnostic mammogram or ultrasound, but he said that usually requires a request from a provider.
Hawaii Pacific Health also said that patients can schedule a mammogram themselves, but said it highly recommends that patients have a primary care doctor or OB-GYN who can review their test results with them.
