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Many readers had strong reactions to my column last week on a recent JAMA studythat upends conventional wisdom on mammograms. The paper found that, compared to current recommendations to begin mammograms for all women at age 40, tailoring the screenings to individual risk was just as effective at detecting breast cancer and more effective at preventing advanced disease among highest-risk women.
Sue from Maryland was among dozens who wrote to say that a mammogram saved her life. “I was shocked when I was diagnosed with breast cancer. I was 41. No family history. My cancer was already Stage 3, but I was able to get treatment and I am now in remission.” She and others worry that women could misinterpret the findings and stop getting mammograms altogether.
To be clear, no one — and certainly not the study’s authors — is suggesting that women forgo mammograms. Rather, emerging evidence suggests the current one-size-fits-all approach to breast cancer screening is outdated and can be better individualized to identify and protect women at elevated risk.
The study’s lead author Laura Esserman, a breast cancer surgeon, told me in an interview that she never treats breast cancers as if they are all the same. “I need to know what the biology is and tailor their treatment to their biology,” she said. Cancers that grow in response to estrogen or progesterone, for example, are treated differently from those that don’t.
That same personalized approached, she believes, should apply to screening and prevention, especially since research has identified specific genes linked to breast cancer risk. The best known are BRCA1 and BRCA2, but multiple other genetic variants can also increase risk. That raises a simple question: Why not identify those at highest risk earlier and design preventive methods accordingly?
Esserman notes that this approach is already routine in other areas of medicine. For instance, cardiologists assess patients’ risk for heart disease by evaluating factors such as blood pressure, diabetes, cholesterol levels and family history. Those at higher risk undergo closer monitoring and additional testing, such as cardiac stress testing or coronary calcium scans. These patients are also counseled on risk reduction, including controlling blood sugar, losing weight and increasing physical activity.
It makes sense that cancer prevention would follow a similar path. Still, after decades of emphasizing the annual mammogram, it’s understandable that many readers feel uneasy about the change. As Anna from Vermont wrote, why fix something that’s not broken?
But the current screening approach is not working as well as it could. As Esserman explained, “If you are at very high risk, screening every year is not good enough. If you are at lower risk, you don’t need to do all that.” She often reminds patients that more testing is not necessarily better. “Sometimes, more is just more; sometimes, more is worse.”
A few readers also questioned whether people would even want to know their genetic risks. “I’ve read psychology studies that if people are given a shorter time to live, they will just give up living,” Kate from Pennsylvania wrote. “Aren’t there ethical implications of telling people they are more likely to develop cancer?”
Esserman’s response is nuanced. Everyone inherits genes that influence their risk for various medical conditions. When people understand what those risks mean, she argued, the information can be empowering rather than paralyzing. Clinicians can guide them to start screening earlier and take steps to lower their risk.
Moreover, the trial suggests that most people would, in fact, want to know their risk. When Esserman and her colleagues first launched the study, critics warned that few women would accept risk-based screening. To make recruitment easier, the researchers allowed women who did not want to be randomly assigned to choose for themselves. Among the roughly 18,000 women who opted to do so, nearly 90 percent selected risk-based screening instead of the annual mammogram. “I think people want things that are tailored to them,” Esserman said.
Importantly, the individualized approach is not solely based on genetic predispositions. A 2024 Lancet report estimated that as many as 25 percent of breast cancer cases in high-income countries are linked to changeable factors such as obesity, smoking and physical inactivity. Esserman’s team developed a risk prediction tool that integrates genetic information with these and other factors. They propose that every woman conducts a risk assessment at age 30 and continually revisit it as circumstances change, such as when a family member is diagnosed with breast cancer.
“A personalized approach to risk assessment sounds good in principle, but how do we have the resources to do this?” asked Mary from D.C. “Compare that to a mammogram, which is free under the Affordable Care Act.”
Mary is right that there are real barriers to immediately implementing risk-based screening. Genetic testing may not be covered by insurance, and not every woman has access to a clinician who can carefully assess risk factors. Over time, however, risk-based screening could save money by reducing unnecessary mammograms while preventing more advanced cancers — especially if insurance coverage evolves to support this approach.
Esserman emphasizes that the cost of a genetic test is less than that of a mammogram, and the results are valid for life. “If you were a low-income country that didn’t have resources for big screening programs, doing the genetic testing and finding those highest-risk people is the most important thing you can do,” she said.
Speaking with Esserman has genuinely changed my thinking. Three years ago, I wrote a column applauding the U.S. Preventive Services Task Force for lowering the recommended age for routine mammograms from 50 to 40. I was persuaded by data showing rising rates of breast cancer in younger women and felt strongly that expanding screening was necessary to catch disease earlier.
Now, I am convinced there is a better way to accomplish this goal. Mammograms are not being discarded, but they are being repositioned for a more nuanced approach to breast cancer prevention. The larger shift is toward understanding risk, reducing it when possible and focusing the most intensive screening on those who stand to benefit the most. This mindset may ultimately reshape how we approach other cancers and life-altering chronic diseases, too.
The post The case for more personalized breast cancer screening appeared first on Washington Post.
