Extending the Age Range in Mammography Screening: A Benefit-Risk Assessment from a Radiation Protection Perspective

TL;DR

The study assesses whether mammography screening benefits women outside the typical 50-69 age range, finding that benefits outweigh radiation risks for older and younger women.

Contribution

The study provides a benefit-risk assessment of extending mammography screening age limits, incorporating radiation risk and mortality data.

Findings

Breast cancer mortality is reduced by 28% in women over 70 and 18% in women aged 39–49.

Radiation risk decreases with older screening start age, with benefit-risk ratios of 25, 35, and 45 for starting at 40, 45, or 50 years.

Abstract

Mammography screening programs (MSP) are established for women age 50 to 69 years in Germany and Europe. Some of the studies that build the evidence base for these programs also included women who were younger or older than this target population. The aim of our study was to assess whether screening also provides more benefit than harm to women outside the originally defined age range of the German MSP.

A systematic review and meta-analysis of randomized controlled trials (RCT) was performed to assess overall and breast cancer mortality in women older than 70 years and women under 50 years. Radiation-associated age-specific lifetime attributable risks (LAR) were estimated based on a modified risk model of the BEIR Committee using current cancer and lifetime data for a female German population.

Two RCTs with 33,268 women age 70 years or older, and eight RCTs with 394,080 women age 39–49 years were included. The relative reduction in breast cancer mortality was 28% (risk ratio (RR) = 0.72; 95% confidence interval (CI): 0.54–0.95) and 18% (RR = 0.82; 95%-CI: 0.71–0.96), respectively. The proportion of overdiagnoses in older women is estimated at 19% and is higher than in younger women. Assuming biennial screening from below 50 to 69 years of age, the LAR decreases considerably with increasing age at start of screening, being 0.06%, 0.04%, and 0.025% when starting at 40, 45, or 50 years, respectively. The corresponding benefit-risk ratios are about 25, 35, and 45, respectively. Changing the upper screening age to 75 has little impact on the benefit-risk ratio.

Extending the age limits in MSP to women starting from 45 years and up to 75 years is justified from the radiation perspective since the benefit substantially outweighs the radiation risk. Based on our report, the MSP has also been approved for women age 70 to 75 in Germany as of February 2024, while it is still pending for younger women.

Screening can reduce breast cancer mortality in women age 45–49 and 70–75.

As a result, more women can benefit from mammography screening programs.

The downside for older women is more overdiagnoses.

Younger women face a higher radiation risk.

Hunger T, Nekolla EA, Wanka-Pail E et al. Extending the Age Range in Mammography Screening: A Benefit-Risk Assessment from a Radiation Protection Perspective. Rofo 2026; 198: 164–172

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