Women who skip their first breast cancer screening appointment are 40% more likely to die from the disease later in life, suggest findings published September 24 in The BMJ.
Researchers led by Wei He, PhD, from Zhejiang University in China and the Karolinska Institute in Stockholm found increased breast cancer mortality among first-screening nonparticipants, which may be explained by lower participation rates in later screenings.
“This increased mortality is modifiable and primarily attributed to late detection,” He and co-authors wrote.
Despite mammography continuing to serve as the gold standard for breast cancer screening, the researchers noted a knowledge gap about the long-term implications of earlier screening behaviors. They suggested that early screening behavior could provide a valuable opportunity to identify high-risk women decades before they develop cancer.
He and colleagues studied the impact of women not attending their first mammography screening invitation on their long-term breast cancer risk.
The study included 432,775 women who received invitations to the Swedish Mammography Screening Programme between 1991 and 2020. The women were initially invited at either 50 years or 40 years of age. The study also included nearly 5 million person years of follow-up, in which the team documented 16,059 new breast cancer cases.
Among women invited to their first mammography screening, 32.1% (n = 138,760) did not participate. Compared with women who participated in their first screening, nonparticipants had odds ratios of 1.53 for stage III cancer and 3.61 for stage IV cancer.
The team also documented 1,603 breast cancer deaths during a total of about 6.8 million person years of follow-up. Not participating in first screening also led to a 25-year cumulative mortality of 9.9 deaths per 1,000 women. Women who participated had a cumulative mortality of 7 deaths per 1,000 women (adjusted hazard ratio 1.40).
However, the 25-year breast cancer incidence remained similar between both groups, including 7.8% in participants and 7.6% in nonparticipants. The researchers suggested that the higher mortality among first screening nonparticipants “likely reflects delayed detection rather than increased incidence.”
The results point to prioritizing nonparticipation at the first screening as an early, actionable predictor of avoidable breast cancer mortality, the authors wrote.
“Screening programs remain insufficiently responsive to this high-risk group, allowing persistent disengagement from preventive care and increasing the likelihood of late-stage diagnoses and death,” they added.
The authors suggested that low-cost interventions such as automatically scheduling a second, fixed date appointment or brief coaching over the phone could improve mammography screening participation.
“By showing that first screening nonparticipants represent a persistently disengaged group … our study provides the essential justification for integrating these proactive strategies into routine mammography screening practice,” they wrote.
In an accompanying editorial, Zhen-qiang Ma, MD, from the Pennsylvania Department of Health in Harrisburg, PA, wrote that the findings also support maintaining public investment in mammography infrastructure, “given that the mortality benefits extend for decades.”
“Even a modest increase in first round participation could yield substantial long-term gains in population health,” Ma wrote. “Breast cancer screening is a decision point with lifelong consequences. Ensuring that women are informed, supported, and empowered to participate in their first screening should be a shared goal across the healthcare system.”
Read the full study here.
