#396 ‒ Breast cancer screening: understanding risk, deciding when to start and how often to screen, and choosing the right imaging strategy

**Peter Attia** (0:11)
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Welcome to a new episode of The Drive. Today, we're diving into breast cancer screening. Why women are still dying from breast cancer despite effective screening tools, where current screening strategies fall short, and how to think about personalizing your own screening. This episode is really about one central question. How do you give yourself the best possible chance of not dying from breast cancer? As we consider this to be a really important public service announcement, the full episode and the detailed show notes for this discussion will be available to everyone, regardless of whether or not you're a premium subscriber. So without further delay, please enjoy this episode of The Drive.
Most of us have heard that terrible statistic. About one in eight women will develop invasive breast cancer over the course of their lifetime. In the United States, roughly 42,000 women die every year from this disease. That makes it one of the leading causes of cancer death behind only lung, colorectal and pancreatic. And yet, despite how common and consequential this disease is, many women have questions about screening, including when it should start, how often to do it, and what factors actually matter. Even women who have looked at the guidelines often come away more confused than before, because the guidance differs between organizations, and it's also shifted over time. And that confusion has real consequences, because breast cancer screening works. Cancers found through screening are more likely to be caught early before they've spread, when treatment is easier and outcomes are better. And that stage shift, as it's called, matters enormously. When breast cancer is caught at stage one, the 10-year survival is over 96%.
By stage four, five-year survival is only around 30%.
It's no surprise, then, that women who screen regularly are up to 40% less likely to die from the disease. Now, of course, screening is not without trade-offs. For example, overdiagnosis of lesions that would never progress to cancer can increase health care burden with no real benefit and remains an area of ongoing uncertainty.
We'll get into these considerations later, but they do not negate the core point. Screening is one of the most effective tools we have for reducing breast cancer mortality. And if you're optimizing for your individual risk of dying from breast cancer, not population efficiency, not total societal cost, but your own outcome, the default should be to err on the side of more effective screening, and certainly not less, which raises the obvious question. If screening works so well, why are so many women still dying from breast cancer every year?
Part of the answer is biology.
Some breast cancers are simply more aggressive than others. They grow quickly, they spread early, and can be difficult to intercept, even with a very good screening system. Some back of the napkin math suggests that somewhere around 7-10 percent of cases are the ones we are unlikely to catch even with perfect screening. But those biologically aggressive cases are not the only reason this disease is still taking so many lives. A major and much more solvable part of the problem is far more mundane. We are still under screening. And I don't just mean that some women never get a mammogram, though that is certainly part of it. Even among women who have been screened before, screening may be inconsistent. Roughly a third of women over 40 have not had a mammogram in the past two years. And even among women aged 50 to 74, where the evidence is most universally agreed upon, about 20% are not up to date.
Under screening has two layers. The first is pretty basic. Most women are not even getting routine mammography at the right time. But the second is more nuanced. Some women are getting screened, but not with the right strategy for their risk profile. This is one statistic that I think captures this perfectly. According to the criteria laid out by major screening guidelines, at least 9% of women meet the threshold for breast MRI as part of their screening protocol.