Performance of First Mammography Examination in Women Younger Than 40 Years

Performance of First Mammography Examination in Women Younger Than 40 Years
Bonnie C. Yankaskas, Sebastien Haneuse, Julie M. Kapp, Karla Kerlikowske, Berta Geller, Diana S. M. Buist, for the Breast Cancer Surveillance Consortium
J. Natl. Cancer Inst. 2010 102: 692-701

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Few data have been published on mammography performance in women who are younger than 40 years.

Results: For screening mammograms, no cancers were detected in 637 mammograms for women aged 18–24 years. For women aged 35–39  years who had the largest number of screening mammograms (n = 73 335) in this study, the recall rate was 12.7% (95% confidence interval [CI] = 12.4% to 12.9%), sensitivity was 76.1% (95% CI = 69.2% to 82.6%), specificity was 87.5% (95% CI = 87.2% to 87.7%), positive predictive value was 1.3% (95% CI = 1.1% to 1.5%), and cancer detection rate was 1.6 cancers per 1000 mammograms (95% CI = 1.3 to 1.9 cancers per 1000 mammograms). Most (67 468 [77.7%]) of the 86 871 women screened reported no family history of breast cancer. For diagnostic mammograms, the age-adjusted rates across all age groups were: sensitivity of 85.7% (95% CI = 82.7% to 88.7%), specificity of 88.8% (95% CI = 88.4% to 89.1%), positive predictive value of 14.6% (95% CI = 13.3% to 15.8%), and cancer detection rate of 14.3 cancers per 1000 mammograms (95% CI = 13.0 to 15.7 cancers per 1000 mammograms).

Mammography performance, except for specificity, improved in the presence of a breast lump.

Conclusions: Younger women have very low breast cancer rates but after mammography experience high recall rates, high rates of additional imaging, and low cancer detection rates. We found no cancers in women younger than 25 years and poor performance for the large group of women aged 35–39 years. In a theoretical population of 10 000 women aged 35–39 years, 1266 women who are screened will receive further workup, with 16 cancers detected and 1250 women receiving a false-positive result


EDITORIAL: Mammography in Younger Women: The Dilemma of Diminishing Returns
Ned Calonge
J. Natl. Cancer Inst. 2010 102: 668-669

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There are a number of breast cancer screening guidelines for younger women that have been published by prominent health and medical groups including the American Cancer Society (2) and the American College of Radiology (3) that advocate screening starting at approximately age 30 years (or 10 years before the premenopausal diagnosis of breast cancer in their relevant relative) for women with BRCA1  and/or BRCA2 mutations or who are otherwise at increased risk for breast cancer.

The American Cancer Society recommendation also states that "because the evidence is limited regarding the best age at which to start screening, this decision should be based on shared decision-making between patients and their health care providers, taking into account personal circumstances and preferences."

The BCSC analysis provides a retrospective insight on the benefits and harms that might accompany such screening. It is, however, critical to point out that this article investigates mammography only and not the use of magnetic resonance imaging or ultrasound in combination with mammography in screening younger high-risk women.

On the basis of this study alone, it is difficult to extend this recommendation to women with BRCA1 and/or BRCA2 mutations  or to other screening modalities, but this same information should be useful in all screening discussions with younger women. If other modalities (such as magnetic resonance imaging) only improve detection rates without improving important health outcomes, recommendations for the use of these modalities may not be warranted, especially if there is a disproportionate increase in false positives (hopefully decreased by modalities such as ultrasound)