Risk-Based Breast Cancer Screening Challenges the Status Quo.
- 4 days ago
- 2 min read
New research published in JAMA from the Women Informed to Screen Depending on Measures of Risk (WISDOM) study is poised to ignite a change in clinical breast cancer screening guidelines. The study, led by Dr. Laura Esserman, found that stratifying screening intensity, modality, and age to start screening by individual risk is safe and acceptable.
The WISDOM trial compared a risk-based screening cohort (14,212 women) against an annual screening cohort (14,160 women). Researchers found that the rate of stage IIB cancers—advanced cancers where mortality risk sharply rises—was noninferior in the risk-based group. Crucially, women undergoing personalized screening had approximately 30 cases of advanced cancer per 100,000 person-years, significantly lower than the 48 cases per 100,000 person-years seen in the annual screening group. This represents a nearly one-third reduction in advanced cancers.
The personalized approach used by the WISDOM team incorporates detailed risk assessment, including sequencing nine susceptibility genes, polygenic risk scoring, lifestyle factors, and breast density. Proponents argue this approach can shift resources from low-risk women to high-risk women, guiding screening frequency and the use of supplemental imaging like MRI.
The study also highlighted the shortcomings of relying solely on family history: 30% of women who tested positive for high-risk genetics did not report a family history of breast cancer. This supports the argument for routine genetic testing, potentially beginning at earlier ages. Esserman emphasized that “More screening isn’t better; smarter screening is”.
Despite the positive findings, major associations caution against immediate changes to current guidelines. The American College of Radiology (ACR) responded, asserting that the study's design and results “do not provide adequate information to support changes to present screening policies”.
The ACR pointed to several concerns, including "substantial nonadherence" to screening among participants and that the trial only recorded outcomes for stage IIB or higher cancers. Furthermore, the ACR stated that the trial's methods, which required "intense breast health specialist intervention," may be difficult to replicate in many clinical settings.
The Society of Breast Imaging (SBI) issued a separate, stronger critique, calling the WISDOM trial "contaminated and underpowered" due to "significant methodological flaws," concluding the trial’s findings are “unsupported”.
Researchers plan to continue the work with WISDOM 2.0, focusing on refining risk models and predicting risk to improve breast cancer prevention efforts.
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Keywords: Risk-based breast cancer screening
Risk-based breast cancer screening
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