Cancer is the second leading cause of death in US women. Lung cancer has the highest mortality rate in the United States, followed by breast cancer, colorectal cancer, and pancreatic cancer. The incidence of new cancer cases per year in the United States is highest for breast cancer, followed by lung cancer, colorectal cancer, and uterine cancer. Cancer incidence and mortality rates are higher for many under-resourced communities. Cancers with effective screening programs include lung, breast, colorectal and cervical cancers. Clinicians should offer screening for these cancers to all women who meet criteria.
Key points
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Women aged 40 to 74 years who are of average risk should be offered breast cancer screening with mammography every 2 years.
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Women aged 21 to 65 years should be offered cervical cancer screening every 3 to 5 years via cervical cytology alone, human papillomavirus testing alone, or co-testing.
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Women aged 45 to 75 years who are of average risk should be offered colon cancer screening via a stool-based test every 1 to 3 years or via a direct visualization-based test every 5 to 10 years.
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Women who are aged 50 to 80, have a 20 pack-year smoking history and either smoke, or have quit within the past 15 years, should be offered lung cancer screening with annual low-dose computed tomography.
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Ovarian cancer screening is not recommended for average risk women.
| ACG | American College of Gastroenterology |
| ACOG | American College of Obstetricians and Gynecologists |
| ACR | American College of Radiology |
| ACS | American Cancer Society |
| CRC | Colorectal cancer |
| CT | computed tomography |
| FDA | US Food and Drug Administration |
| FIT | fecal immunochemical test |
| HPV | human papillomavirus |
| LDCT | low dose CT |
| NCCN | National Comprehensive Cancer Network |
| SBI | Society of Breast Imaging |
| sDNA-FIT | stool DNA-FIT |
| TVUS | transvaginal ultrasound |
| USPSTF | United States Preventive Services Task Force |
Introduction
Globally, cancer is second only to cardiovascular disease as the leading cause of death in women. , In the United States, cancer continues to account for approximately 20.5% of deaths in women. With an aging global population, the crude cancer death rate rose by approximately 21% since 1990. Although overall incidence rates continue to rise, global age-standardized rates of cancer deaths have decreased by approximately 15%, suggesting improvement in cancer screening, diagnosis, and treatment efforts.
Cancer screening programs remain essential tools in early detection and diagnosis of cancer. Mathematical modeling suggests that increased screening increases early detection and decreases cancer mortality , ; although, the degree of impact is perhaps debatable. , In recognition of the importance of screening efforts on early cancer detection, Healthy People 2030 initiatives prioritize increasing cancer screening rates. This article reviews current issues regarding US cancer screening guidelines in women for breast, cervical, colorectal, lung, and ovarian cancers with attention toward cancer-specific special populations and differences in screening rates and outcomes in minoritized communities.
Breast Cancer Screening
Background
Breast cancer is the second most common type of cancer next to skin cancer and has the second highest mortality next to lung cancer in women ( Table 1 ). Since 1999, the incidence of breast cancer has been stable, with approximately 130 cases per 100,000 women annually. Breast cancer mortality rates have dropped over this period, with the age-adjusted death rate decreasing from 26.6 per 100,000 to 19.4 per 100,000 women. This change has stabilized the number of individuals dying from breast cancer to around 40 to 42,000 women a year.
| Cancer Type | 2019 Incidence (# Cases) | Incidence Rate (per 100,000) | 2019 Mortality (# Cases) | Mortality Rate (per 100,000) |
|---|---|---|---|---|
| All | 899,200 | 432.6 | 283,722 | 125.9 |
| Breast | 271,950 | 133.6 | 42,280 | 19.4 |
| Lung | 113,928 | 50.6 | 64,743 | 28.1 |
| Colorectal | 69,068 | 32.8 | 24,222 | 10.8 |
| Uterine | 61,110 | 28.5 | 11,556 | 5.1 |
| Melanomas | 37,750 | 19.1 | 2797 | 1.3 |
| Thyroid | 34,370 | 19.8 | 1090 | 0.5 |
| Non-Hodgkin’s lymphoma | 33,414 | 15.7 | 8792 | 3.9 |
| Pancreas | 27,107 | 12.1 | 22,153 | 9.6 |
| Kidney | 25,982 | 12.5 | 4795 | 2.1 |
| Leukemias | 22,650 | 11.1 | 9743 | 4.4 |
| Ovarian | 20,466 | 10 | 13,445 | 6 |
| Bladder | 18,639 | 8.3 | 4740 | 2 |
| Oral cavity/pharynx | 14,148 | 6.7 | 3117 | 1.4 |
| Cervical | 13,322 | 7.8 | 4152 | 2.2 |
a Abstracted from publicly available data, see ref.
b At time of writing, data available up to 2022; however, pre-pandemic data chosen due to COVID-19 pandemic effects that are beyond scope of the article.
Current mammography technology is associated with a 41% reduction in mortality and a 25% reduction in rates of advanced breast cancers at time of diagnosis. Sensitivity of screening mammography worsens with increased density of breast tissue (98% sensitive in fatty breast tissue vs 30%–48% in extremely dense tissue). Additionally, women with dense breasts are more likely to develop breast cancer. As of September 2024, breast density is required to be reported to patients and ordering clinicians after mammography. Adjunctive imaging with MRI or ultrasound shows a small increase in detection rates in individuals with dense breast tissue; however, it is also associated with increased false positive and biopsy rates, and mortality benefit has yet to be demonstrated. , While this issue remains a concern, consensus among guideline organizations has not been reached regarding the use of adjunctive imaging in average risk women with dense breast tissue ( Table 2 ).
| Organization | Modality | Start (age, years) | Frequency (years) | End (Age) | Breast Tissue Density |
|---|---|---|---|---|---|
| ACS 2015 | Mammography | 45 option at 40 | 1 (40–54) then 2 (≥55) | Continue past 75 if life expectancy >10 y | Not discussed |
| ACOG 2017 | Mammography + offer clinical breast examination starting age 25 years | 40 | 1 (40–54) then 2 (≥55) | 75 or longer with shared decision making | Recommend against (ACOG #625) |
| NCCN 2023 | Mammography + tomosynthesis | 40 | 1 | Not specified | Consider supplemental imaging for heterogenous or extremely dense tissue |
| USPSTF 2024 | Mammography ± tomosynthesis | 40 | 2 | 75 (insufficient evidence past 75) | Insufficient evidence for supplemental imaging |
| ACR/SBI 2021 | Mammography + offer risk assessment by age of 30 years | 40 | 1 | Continue past 75 unless severe comorbidities | Insufficient evidence, however, based on ACR appropriateness criteria: consider supplemental imaging based on density and risk |
Breast cancer screening rates in the United States are stable with 76.4% of women aged 50 to 75 years receiving recommended screening (2019). Screening rates increase with affluence (<200% federal poverty level, 68.3%, >200% 79.6%) and higher educational achievement (less than high school, 69.4%; high school 73.2%; above high school 79.0%).
Screening recommendations
Screening recommendations for breast cancer are based on risk factors and age. Average risk women are healthy women without additional genetic, radiation exposure, or family history-related risk factors.
Average risk
As detailed in Table 2 , with the 2024 United States Preventive Services Task Force (USPSTF) update, the major screening recommendations for average risk individuals are now nearly all aligned to start screening with mammography at the age of 40 years. , , , , , Among the major guideline organizations (USPSTF, American Cancer Society [ACS], American College of Obstetricians and Gynecologists [ACOG], National Comprehensive Cancer Network [NCCN], American College of Radiology [ACR], and the Society of Breast Imaging [SBI]), there is still heterogeneity regarding frequency of screening. For most average risk women, there is room for an individualized approach to screen yearly versus biennially based on age, patient preferences, breast density, and availability of advanced imaging modalities. All organizations recommend continuing screening until the age of 75 years and continuing beyond 75 years to be individualized based on health and life expectancy of at least 10 years.
Moderate risk
Moderate risk women are those with a family history of breast cancer at age greater than 40 years without a known genetic predisposition syndrome to cancer. The most recent ACR guidelines recommend risk assessment by the age of 30 years for all women. Risk assessment tools such as the Tyrer Cuzick model or BOADICEA/CanRisk are available to help patients and clinicians further risk stratify and determine whether high risk recommendations should be followed. , For women older than 35 years of age, the modified Gail model is an option to assess 5 year risk. The NCCN suggests following high-risk recommendations for those with greater than 20% lifetime risk or greater than 1.7% 5 year risk of invasive breast cancer. For most organizations, recommendations do not change in moderate risk women from average risk women.
High risk
High risk women are those with a family history of first-degree relatives at a young age, prior chest radiation, and/or known genetic predispositions. Most organizations recommend yearly screening for women in this category beginning at the age of 30 years with yearly mammography and breast MRI. , , , , , If there are known family history of specific genetic markers, such as BRCA1 and 2, family members should also consider genetic counseling.
Disparities
Racial disparities in breast cancer mortality persist. Despite the non-Hispanic black population having the highest overall screening rates (79% in 2019, 82% in 2021), this population continues to have the highest breast cancer mortality rate (40% higher risk compared to a non-Hispanic white population). Reasons are multifaceted, complex, and linked to social determinants of health which are worse in minoritized and lower resourced communities.
Cervical Cancer Screening
Background
Cervical cancer is the 14th most common type of cancer in US women (see Table 1 ). The annual incidence and mortality rates of cervical cancer have remained stable since 2012 through 2019 at around 7.8 per 100,000 new cases and around 2.2 per 100,000 deaths. Rates of screening in the United States are high (>80% in 2019) but vary by age, ethnicity/race, socioeconomic, education, and geographic location. Screening rates are lower in minoritized racial and ethnic groups, rural residents, sexual and gender minorities, those with limited English proficiency, and with mental health conditions. Infection with a high-risk strain of human papillomavirus (HPV) is associated with nearly all cases of cervical cancer. Transmission of HPV occurs through sexual intercourse. Since the approval of the first HPV vaccine in 2006, studies show promising results in the youngest birth cohorts who are vaccinated, with 65% to 88% estimated reduction in cervical cancer incidence rates. , HPV vaccination rates have approached approximately 70% of US girls.
Screening recommendations
As summarized in Table 3 , most guideline organizations recommend routine screening with every 3 year Pap smear starting at age 21 years up to age 30 years. At age 30 years and above, the USPSTF recommends continued screening with every 3 year Pap, or Pap with HPV co-testing every 5 years until the age of 65 years. The ACS recommends HPV only testing every 5 years starting at age 25 years through 65 years as another option. Screening is recommended regardless of HPV vaccination status. Women who have a hysterectomy with removal of the cervix, and who do not have a history of cervical intraepithelial neoplasia grade 2 or 3 or cervical cancer do not need continued cervical cancer screening. Women above the age of 65 years should only be screened if they have not received adequate prior screening, defined as 3 consecutive negative cytology results or 2 consecutive negative co-testing results within the prior 10 years, with the most recent test having occurred in the past 5 years. Women with a precancerous cervical lesion (CIN 2 or greater) should continue screening for at least 20 years after treatment or spontaneous regression of the lesion. A new sexual partner after the age of 65 years is not an indication to re-start cervical cancer screening in a person who otherwise meets criteria to stop screening. ,
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