2 Decades of Mammography Trends Reveal Gaps in Screening Among Uninsured and Minority Women

Mammography use showed a nonsignificant overall downward trend from 2002 to 2022, but significant declines occurred among younger women, according to a large cross-sectional study published in JAMA that drew on data from over 2.6 million US women. These groups that had a significant decline included those who are uninsured, unmarried, non-Hispanic White, or Asian. This negative trend was exacerbated by the 2009 US Preventive Services Task Force (USPSTF) guideline change recommending against routine screening for women aged 40 to 49 years, after which mammography use decreased further.¹

Overall, mammography prevalence declined from 69.9% to 59.2% among women aged 40 to 49 years and from 81.3% to 77.0% in women aged 50 to 74 years, but neither trend reached statistical significance at the population level. The significant declines were concentrated in specific subgroups.

Among women aged 40 to 49 years, the steepest statistically significant declines were seen in those without insurance (−1.54% per biennium), current smokers (−1.36%), unmarried women (−1.10%), and non-Hispanic White women (−0.58%). Following the 2009 guideline change specifically, significant declines were seen among non-Hispanic White (−0.88%), Asian (−2.45%), and uninsured women (−2.39%), while no significant reduction occurred among non-Hispanic Black women (−0.59%; 95% CI, −1.20% to 0.03%).

Geographically, Western states, particularly in the Rocky Mountain and Southwest regions, consistently showed lower mammography prevalence than Eastern states across both age groups and across the entire study period. Vermont and New Mexico had the largest state-level declines among women aged 40 to 49 years. South Dakota and Mississippi were the only states to show significant increases in this group.

The results carry particular weight because in 2024, the USPSTF reversed course on its 2009 position and now recommends biennial screening mammography for all women aged 40 to 74 years. Additionally, the COVID-19 pandemic disrupted access to preventive services such as mammography, which may have exacerbated barriers to care. Understanding what happened to screening rates during the intervening 15 years provides critical context for clinicians trying to reengage patients who may have stepped away from routine mammography.

Researchers from Washington University School of Medicine analyzed data from the CDC

s Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative telephone survey, across all biennial cycles from 2002 to 2022. The final data set included over 2.6 million women aged 40 to 74 years who had reported mammogram use within the past 2 years. The study examined trends by age group (40-49 and 50-74 years) and stratified results by race and ethnicity, education, income, insurance status, marital status, employment, health care access, smoking, physical activity, and geography.

Importantly, the study accounted for a major BRFSS survey change in 2011 as the system expanded to include cellphone-only households and adopted new weighting methods. Prior studies had not accounted for this shift, which the authors argue “may have substantially influenced prevalence estimates.”

The persistence of lower mammography rates among uninsured women reflects the idea that financial and structural barriers have an outsize effect on preventive care. But the declines observed among insured women and those with a regular health care practitioner after the 2009 guideline change suggest that something else is also at work. As the authors note, "these patterns suggest that changes in national guidelines can subtly yet meaningfully influence preventive care uptake, even among populations for whom recommendations remain unchanged."

The racial divergence in screening trends showed that non-Hispanic Black women, who face substantially higher breast cancer mortality risk than their White counterparts, had steadier mammography participation rates following the 2009 guideline change. The authors suggest targeted safety-net programs, such as the National Breast and Cervical Cancer Early Detection Program, may have helped buffer declines in this population.

These findings are particularly relevant given that breast cancer incidence in women younger than 50 years has been rising at approximately 1.4% per year, faster than in older women.² Declining screening rates in younger age groups, even if partially guideline-driven, risk shifting diagnoses toward later stages, impacting survival.

The 2024 USPSTF update recommending screening to begin at aged 40 years provides a clear opportunity to address these trends. However, simply updating the recommendation is unlikely to be sufficient as the data suggest that subgroups of younger women who already had lower participation rates (including those uninsured, unmarried, or living in the Western US) were not meaningfully engaged during the prior guideline era and may require targeted outreach to reach guideline-concordant care now.

References

1. Al Hasan SM, Bennett DL, Toriola AT. Trends in mammography use among women aged 40 to 74 years in the US, 2002-2022. JAMA Netw Open. 2026;9(3):e263529. doi:10.1001/jamanetworkopen.2026.3529

2. Giaquinto AN, Sung H, Newman LA, et al. Breast cancer statistics 2024. CA Cancer J Clin. 2024;74(6):477-495. doi:10.3322/caac.21863