by Erin Steigleder, MSW, Director of Programs
New Breast Cancer Screening Guidelines Are Causing Confusion
On April 20th, 2026, the American College of Physicians (ACP), an association of internal medicine physicians, issued new guidance on breast cancer screening, and a number of other medical associations are not happy about it. In fact, here is a quote from the joint statement from the American College of Radiology (ACR) and the Society for Breast Imaging (SBI), “ACR and SBI respect ACP’s efforts to advocate for our shared patients across many medical conditions and indications, but ask ACP to defer to breast cancer diagnosis and treatment experts regarding this matter.” Essentially saying, “sit down, you don’t know what you’re talking about.”
What Changed in the New Screening Guidelines?
What kind of guidance would cause all of this drama? The ACP’s new guidance recommends that women of average risk of developing breast cancer should start biennial screenings at age 50, and women in that population at ages 40-49 should have a conversation with their doctor about the benefits and risks of screening. Additionally, digital breast tomosynthesis, or 3D mammograms, are recommended for women with dense breasts, but supplemental ultrasounds and MRIs are not. These recommendations may sound familiar because they are pretty similar to what the United States Preventive Services Task Force (USPSTF) used to recommend, until they updated them in 2024. And that’s part of the problem; these recommendations are a step backward and do not reflect our current breast cancer realities.
Why Are Experts Pushing Back?
Unfortunately, current recommendations from ACR, USPSTF, the National Comprehensive Cancer Network, and the American Cancer Society are all over the place, so there is no clear guidance against these recent ACP guidelines. However, all of these groups recommend screening at least by 45, if not 40, if a woman is of average risk of developing breast cancer. And most recommend supplemental imaging for women who have extremely dense breasts.
Why Would ACP Make These Recommendations?
Why would the ACP make recommendations that are so different from the current consensus? Likely because they have such a broad perspective on healthcare, rather than a specialized view. Internal medicine physicians see everything, so although breast cancer is the most commonly diagnosed cancer in women, internal medicine physicians see a lot more people with high blood pressure, diabetes, asthma, etc. than breast cancer. Using the population lens, breast cancer is relatively rare in women under age 50 compared to women over the age of 50, so in their minds, it makes more sense to concentrate screening in the women over 50 who are more likely to develop breast cancer. They see having more than one or two women under 50 with breast cancer in their practice as a fluke; however, the experts in breast cancer care have a better view of the overall breast cancer diagnostic trends. Breast cancer diagnosis is actually increasing at a faster rate for some women under 50 than for women over 50. And breast cancer diagnosed at a younger age is often more aggressive and therefore more likely to spread, so time really is of the essence for younger women with the disease.
What Does “Average Risk” Really Mean?
Another issue with the recommendations is how the ACP defined “average risk.” The ACP defined average risk as “females who do not have a personal history of breast cancer or diagnosis of a high-risk breast lesion, a genetic mutation such as BRCA1/2 that is known to increase risk, another familial breast cancer risk syndrome, or a history of high-dose radiation therapy to the chest at a young age.” This completely ignores the risk of breast density, alcohol consumption, early puberty, and other breast cancer risk factors that may have a lesser impact than a genetic mutation but are more common throughout the population.
What the WISDOM Trial Revealed
Additionally, with the recently published WISDOM trial, we learned that not everyone has a clear idea of what their genetic risk of breast cancer might be. During that trial, women were screened for genetic mutations related to breast cancer regardless of their family history as a part of a larger study on individualized breast cancer screening recommendations. As a surprise to all, 30% of women who tested positive for a genetic mutation for breast cancer did not appear to be at high risk, meaning that they did not have breast or ovarian cancer in their family. Therefore, the ACP would have defined these women as average risk and they would have not been recommended for genetic testing and would miss out on earlier screening. With the new information received from the WISDOM trial, we need to be wary about deciding who is and who isn’t average risk without proper risk assessments.
Are the “Harms” of Screening Being Overstated?
And finally, we take issue with the “harms” of screening at ages 40-49 that the ACP listed, so let’s take a look at each of them. Number one: false positive results. This just means that the imaging found something that might be cancer but turned out not to be cancer, not that the person is actually diagnosed with a cancer that they do not have. False-positive results decrease with improved technology, like 3D mammography. Yes, they do happen and they can cost patients and the system money that doesn’t need to be spent, but the answer to that isn’t “screen less”, it’s to improve the accuracy of the technology.
False Positive Results
Number two: psychological distress. Mammograms can be uncomfortable, even painful, and nerve-racking, absolutely. However, it is the responsibility of the medical team to make patients feel comfortable as they go through medical tests. Their prescribing doctor can answer their questions about mammography, and the technicians can listen to concerns about discomfort and try to reduce any discomfort that the patient has. The answer to “I’m scared about this test” is not “don’t test” but rather “how can we make this process better for you?”
Overdiagnosis and Overtreatment
Overdiagnosis and overtreatment are the last “harms” listed that we’ll discuss. (Radiation is also listed, but we go into that in this blog) Overdiagnosis is what happens when someone is diagnosed with a cancer that maybe wouldn’t have posed a threat to their life, and overtreatment is when the treatment is too aggressive for what the cancer called for. These can unfortunately only really be assessed after the fact, if at all, so hindsight is 20/20, but many women and their medical teams would rather not take the risk to undertreat. Overdiagnosis happens because we don’t yet know enough about metastasis, cancer spreading to other organs, and when and why it happens, so we treat every breast cancer as if it is going to spread. So again, the answer to this problem is not “screen less” but to improve our research into metastasis and “watchful waiting” strategies like those employed with prostate cancer, so that in the future, we can diagnose more appropriately.
An example of overtreatment is someone opting to have their breasts removed when they clinically only need a lumpectomy, or opting for radiation treatment to reduce the risk of recurrence by only a small percentage (in some cases). These decisions often happen because the patient is younger and concerned about recurrence, or they want to do everything possible to potentially eliminate their risk of cancer in the future due to fear. Yes, these decisions cost the patients and the system more money and can cause unnecessary hardships for the patient, but why is it considered ok to avoid screening for “psychological distress” but not for a patient to adjust their treatment plan for the same reason? If a patient is fully informed of all the risks and benefits of screening and their treatment options, shouldn’t the medical decision be up to them? Almost all of the “harms” listed by ACP are not inherent to getting screened for breast cancer annually in your 40s, but are a result of how our medical system works or our need to learn more about how breast cancer behaves.
What’s Our Take?
What’s our take? We think it would be a lot easier if the cancer experts could get on the same page when it comes to screening recommendations. There is currently a lot of variation that makes it confusing to know what you are supposed to do. But from where we are sitting, the ACP’s list of “risks” for screening between the ages of 40-49 is not enough to overcome the increase in breast cancer diagnosis we are seeing in that age group.
What Should You Do Next?
Ideally, every woman should have a conversation with her doctor before the age of 40 about what her individualized breast cancer risk is, taking into account individual risk and protective factors. Then the woman can come up with her own screening plan, with her doctor, while having all of the relevant information. So please, get screened in your 40s. If you have dense breasts, talk to your doctor about what it looks like to add supplemental screening to your regular mammograms. Depending on your health insurance plan, you may be eligible to get additional testing at no out-of-pocket cost. To learn more about breast cancer screening, take a look at our blog on the six breast cancer screening tests.
