Original Title: Enjeux, considérations et modalités de mise en œuvre entourant l’accès au dépistage du cancer du sein chez les femmes âgées entre 40 et 49 ans au Québec

Authors' objectives: The recommendations concerning the optimal age for initiating systematic screening for women at average risk is debated in the clinical and scientific community. In Canada and abroad, different screening modalities are available to women aged 40 to 49 years. Presently, in Québec, women in this age group have to obtain a medical referral for a screening mammogram. The Minister of Health having expressed his will to facilitate access for this age group, the Institut national d’excellence en santé et en services sociaux (INESSS) was asked to examine the issues associated with such an initiative and to make recommendations aimed at guiding and optimizing its rollout. In keeping with this request, this work was not aimed at taking a position for or against breast cancer screening in women under the age of 50.

Authors' results and conclusions: RESULTS (#1 BREAST CANCER SCREENING FOR WOMEN AGED 40 TO 49 YEARS-OVERVIEW AND EPIDEMIOLOGY): In 2025, the number of women aged 40 to 49 years in Québec was estimated at 585,800, representing 13% of the female population. This group will experience moderate growth of 3.9% by 2035, due mainly to women aged 40 to 44 years (#2 BREAST CANCER SCREENING FOR WOMEN AGED 40 TO 49 YEARS-RISK FACTOR-BASED SCREENING STRATEGIES): In the current context, the only feasible strategy for trying to increase screening in Québec women with certain individual risk factors is based on age, together with an informed, shared decision-making process using tools that emphasize the impact of different factors on the risk of developing breast cancer. (#3 BREAST CANCER SCREENING FOR WOMEN AGED 40 TO 49 YEARS-BENEFITS AND HARMS REPORTED BY LEARNED SOCIETIES OF SCREENING WOMEN IN THEIR FORTIES): Several of the stakeholders consulted felt that early screening can detect cancers at a less advanced stage, which translates into less aggressive treatments and a potential improvement in the patient’s quality of life. (#4 BREAST CANCER SCREENING FOR WOMEN AGED 40 TO 49 YEARS-LEARNED SOCIETIES’ POSITION): A 2-year interval is generally preferred to annual screening in order to reduce the associated drawbacks. Digital mammography is widely recognized as the standard modality. (#5 BREAST CANCER SCREENING FOR WOMEN AGED 40 TO 49 YEARS-PERSPECTIVES OF THE POPULATION AND PROFESSIONALS): The scientific literature suggests that most women in this age group are also in favour of screening starting in one’s forties. (#6 BREAST CANCER SCREENING FOR WOMEN AGED 40 TO 49 YEARS-MODELING): Canadian modelling results in the literature suggest that biennial breast cancer screening of women aged 45 to 74 years or annual screening between the ages of 40 and 49 years followed by biennial screening from 50 to 74 years would constitute the most clinically effective and economically cost-effective implementation approach, compared to the biennial screening presently offered to women aged 50 to 74 years. However, the assumptions on which these models are based, such as an ideal participation rate of 100% and no organizational constraints, limit their applicability to the Québec context and reduce the significance of the projected results. (#7 BREAST CANCER SCREENING FOR WOMEN AGED 40 TO 49 YEARS-OTHER ISSUES TO CONSIDER REGARDING EXPANDED ACCESS TO SCREENING): The general recall rate, which is already high, could increase by 2.5 to 5.0% with the inclusion of women starting at age 45 or 40 because of their higher breast density. The wait times for a screening mammogram or an additional examination, diagnostic wait times (especially for biopsies) and surgical wait times would likely increase in all age groups with the inclusion of women aged 40 to 49 years. (#8 BREAST CANCER SCREENING FOR WOMEN AGED 40 TO 49 YEARS-COST-EFFECTIVENESS OF EXPANDING ACCESS TO SCREENING FOR WOMEN AGED 45 TO 49 YEARS): In light of the different expansion scenarios considered, the feasibility issues, the clinical benefits and harms of each, and the anticipated considerable impact on the health-care system’s resources, the most realistic scenario selected by the different stakeholders consulted for a first step in expanding screening access would be biennial invitation, by means of a letter, to women aged 45 to 49 years. (#9 BREAST CANCER SCREENING FOR WOMEN AGED 40 TO 49 YEARS-BUDGET IMPACT OF EXPANDING ACCESS TO SCREENING FOR WOMEN AGED 45 TO 49 YEARS): Decreasing the callback rate in order to achieve the ministerial targets for women aged 50 to 74 would reduce the cost of the existing program by more than $47 million over 5 years, or about 27% of the net impact of including women aged 45 to 49 years. Upon achieving these targets, the additional costs associated with this expansion would be reduced by $26.1 million, which would be a further decrease of 15%. (#10 BREAST CANCER SCREENING FOR WOMEN AGED 40 TO 49 YEARS-MEASURES FOR SUPPORTING SCREENING): Health professionals generally feel ill-equipped to discuss the benefits and harms of screening with women in their forties. Shared-decision support tools are welcomed by the stakeholders concerned.

Authors' recommendations: In light of this analysis, INESSS is of the opinions that expanding access to breast cancer screening for women in their forties entails certain major organizational issues. (RECOMMENDATION 1 – Upgrade the Québec Breast Cancer Screening Program): INESSS recommends that the Québec Breast Cancer Screening Program (PQDCS) be upgraded in order to reduce the recall rates and the examination wait times. This would strengthen the program and improve its cost-effectiveness for all age groups. (RECOMMENDATIONS 2 and 3 – Gradual expansion supported by suitable tools): INESSS recommends the gradual inclusion of women aged 45 to 49 years in the consolidated PQDCS for biennial screening with a targeted invitation. The pace of this expansion should be adjusted at the regional level according to local capacities. (OTHER CONSIDERATIONS – EQUITY OF ACCESS): To improve breast cancer screening participation and decision-making in certain populations that might feel less addressed by the current program, INESSS recommends that targeted efforts be made to better reach groups of women with lower screening participation rates, in particular, those from diverse ethnic, cultural and gender identity backgrounds.

Authors' methods: A systematic review of the scientific literature and clinical practice recommendations was conducted to document the different clinical aspects and issues associated with breast cancer and breast cancer screening. In addition, a narrative review was carried out to shed light on the populational, sociocultural, organizational, and economic considerations regarding the expansion of breast cancer screening to include Québec women aged 40 to 49 years. As well, consultations were held with key stakeholders and players in the health and social services system. Lastly, patient volume estimates were made in collaboration with the Institut national de santé publique du Québec (INSPQ), using data from the Québec Breast Cancer Screening Program (PQDCS), the Registre québécois du cancer (RQC) and the Institut de la statistique du Québec (ISQ). These analyses were aimed at estimating the cost-effectiveness of screening in the Québec context and at assessing the impact of expanded access on resources and the required budget.

Authors' identified further research: The advisability of updating this report will be assessed on the basis of the input of new data supporting any of the aspects examined, in particular, published results from ongoing studies, data collected in a Québec context or any other publication that could have an impact on the screening method used.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/enjeux-considerations-et-modalites-de-mise-en-oeuvre-entourant-lacces-au-depistage-du-cancer-du-sein-chez-les-femmes-agees-entre-40-et-49-ans-au-quebec.html

Year Published: 2025

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/enjeux-considerations-et-modalites-de-mise-en-oeuvre-entourant-lacces-au-depistage-du-cancer-du-sein-chez-les-femmes-agees-entre-40-et-49-ans-au-quebec.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)