Age-based versus Risk-based Mammography Screening in Women 40–49 Years Old: A Cross-sectional Study

Background Risk-based screening in women 40–49 years old has not been evaluated in routine screening mammography practice. Purpose To use a cross-sectional study design to compare the trade-offs of risk-based and age-based screening for women 45 years of age or older to determine short-term outcomes. Materials and Methods A retrospective cross-sectional study was performed by using a database of 20 539 prospectively interpreted consecutive digital screening mammograms in 10 280 average-risk women aged 40–49 years who were screened at an academic medical center between January 1, 2006, and December 31, 2013. Two hypothetical screening scenarios were compared: an age-based (≥45 years) scenario versus a risk-based (a 5-year risk of breast cancer greater than that of an average 50-year-old) scenario. Risk factors for risk-based screening included family history, race, age, prior breast biopsy, and breast density. Outcomes included breast cancers detected at mammography, false-positive mammograms, and benign biopsy findings. Short-term outcomes were compared by using the χ2 test. Results The screening population included 71 148 screening mammograms in 24 928 women with a mean age of 55.5 years ± 8.9 (standard deviation) (age range, 40–74 years). In women 40–49 years old, usual care included 50 screening-detected cancers, 1787 false-positive mammograms, and 384 benign biopsy results. The age-based (≥45 years) screening strategy revealed more cancers than did the risk-based strategy (34 68% vs 13 26% of 50; P < .001), while prompting more false-positive mammograms (899 50.3% vs 216 12.1% of 1787; P < .001) and benign biopsy results (175 45.6% vs 49 12.8% of 384; P < .001). The risk-based strategy demonstrated low levels of eligibility (few screenings) in the 40–44-year age group. Differences in outcomes in the 45–49-year age group explained the overall hypothetical screening strategy differences. Conclusion Risk-based screening for women 40–49 years old includes few women in the 40–44-year age range. Significant trade-offs in the 45–49-year age group explain the overall difference between hypothetical screening scenarios, both of which reduce the benefits as well as the harms of mammography for women 40–49 years old. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Joe and Hayward in this issue.