Bold claim: risk-based breast cancer screening is safe and acceptable, but it doesn’t cut biopsy rates. That’s the core takeaway from the December 12 JAMA publication, which examines results from the Women Informed to Screen Depending on Measures of Risk (WISDOM) study. Led by Laura Esserman, MD, at the University of California, San Francisco, the research found that the rate of stage IIB cancers in women guided by individual risk was noninferior to those undergoing annual screening mammography.
In plain terms, tailoring screening intensity, methods, and the age to start based on a person’s risk can be safe, and it also helps map how risk evolves over time. This approach not only aims to catch cancer at a treatable stage but also builds a foundation for refining risk-based screening down the line.
Supporters of risk-based screening argue that it reallocates resources—from lower-risk individuals to those at higher risk—and informs decisions about when to screen, how often to screen, whether to add supplemental imaging, and what preventive steps might be warranted.
The WISDOM trial is ongoing and investigates whether personalized screening can prevent as many advanced cancers as annual screening. It randomized 28,372 women (average age ~54) into two groups: risk-based screening (n = 14,212) and annual screening (n = 14,160). About 77% of participants were non-Hispanic White.
Key findings include:
- The risk-based group had a stage IIB cancer rate of 30 per 100,000 person-years, which was noninferior to the 48 per 100,000 person-years observed in the annual-screening group.
- Even with fewer mammograms in the risk-based group, biopsy rates were similar between groups (943 vs 1,029; a non-significant difference, p = 0.1).
- Across the study, the cumulative incidence of cancer, biopsy, mammography, and MRI rose with higher risk categories.
- In the observational cohort, 89% of participants chose risk-based screening.
The researchers emphasize that improved risk models and clearer risk-reduction recommendations hold promise for future improvements. They also highlight the importance of better risk communication to patients and clinicians to support informed, shared decision-making. WISDOM 2.0 is in the works, aiming to incorporate polygenic risk scores for subtype- and ancestry-based risk assessment, alongside radiographic risk measures.
ACR’s perspective
The American College of Radiology (ACR) responded by noting that the study’s design and results aren’t sufficient to justify changing current screening policies. They pointed to substantial nonadherence to screening and a lower-than-expected accrual. They also noted that outcomes were recorded only for stage IIB cancers or larger—tumors roughly an inch in diameter that could already be detectable on clinical breast exams or self-breast exams.
ACR’s critique continues: the trial required intensive breast health specialist involvement that may be hard to replicate in typical clinical settings, and even so, adherence to risk-reduction strategies was poor. They also point out that the polygenic risk scores varied in composition across participants, introducing unknowns, and that risk-assessment models generally offer only moderate discriminative ability.
Bottom line
ACR maintains that ongoing appraisal of multiple high-quality studies is essential to determine how—and when—screening strategies should be updated. The full study is available here: https://jamanetwork.com/journals/jama/fullarticle/2842903
Would you like a quick, lay-friendly summary of the study’s methods and patient groups, or a discussion of what risk-based screening could mean for patients and clinicians in practice?
