: Beneficial Effect of Consecutive Screening Mammography Examinations on Mortality from Breast Cancer: A Prospective Study

Background Previously, the risk of death from breast cancer was analyzed for women participating versus those not participating in the last screening examination before breast cancer diagnosis. Consecutive attendance patterns may further refine estimates. Purpose To estimate the effect of participation in successive mammographic screening examinations on breast cancer mortality. Materials and Methods Participation data for Swedish women eligible for screening mammography in nine counties from 1992 to 2016 were linked with data from registries and regional cancer centers for breast cancer diagnosis, cause, and date of death (Uppsala University ethics committee registration number: 2017/147). Incidence-based breast cancer mortality was calculated by whether the women had participated in the most recent screening examination prior to diagnosis only (intermittent participants), the penultimate screening examination only (lapsed participants), both examinations (serial participants), or neither examination (serial nonparticipants). Rates were analyzed with Poisson regression. We also analyzed incidence of breast cancers proving fatal within 10 years. Results Data were available for a total average population of 549 091 women (average age, 58.9 years ± 6.7 [standard deviation]). The numbers of participants in the four groups were as follows: serial participants, 392 135; intermittent participants, 41 746; lapsed participants, 30 945; and serial nonparticipants, 84 265. Serial participants had a 49% lower risk of breast cancer mortality (relative risk [RR], 0.51; 95% CI: 0.48, 0.55; P < .001) and a 50% lower risk of death from breast cancer within 10 years of diagnosis (RR, 0.50; 95% CI: 0.46, 0.55; P < .001) than serial nonparticipants. Lapsed and intermittent participants had a smaller reduction. Serial participants had significantly lower risk of both outcomes than lapsed or intermittent participants. Analyses correcting for potential biases made little difference to the results. Conclusion Women participating in the last two breast cancer screening examinations prior to breast cancer diagnosis had the largest reduction in breast cancer death. Missing either one of the last two examinations conferred a significantly higher risk. © RSNA, 2021 Online supplemental material is available for this article.


INTEREST OF AMICUS CURIAE 1
The Susan G. Komen Breast Cancer Foundation, Inc. ("Komen") is the world's leading nonprofit breast cancer organization. Komen advocates on behalf of the millions of people who have been diagnosed with breast cancer, including more than 300,000 people in the United States who will be diagnosed with breast cancer and almost 44,000 who are expected to die from the disease in 2023 alone.
Komen's mission is to save lives by meeting the most critical needs in communities and investing in breakthrough research to prevent and cure breast cancer. To that end, Komen has an unmatched, comprehensive 360-degree approach to fighting breast cancer across all fronts, including by (1) advocating for patients; (2) driving research breakthroughs; (3) improving access to high-quality care; (4) offering direct patient support; and (5) empowering people with trustworthy information. Komen's work has helped reduce the mortality rate from breast cancer by 43% since its founding in 1982.
However, not all people have benefited equally from progress against breast cancer. Thus, Komen is committed to achieving breast health equity so that all 1 All parties have consented to the filing of this brief. Pursuant to Federal Rule of Appellate Procedure 29(a)(4)(E), amicus states that no counsel for a party authored this brief in whole or in part, and no party or party's counsel made a monetary contribution intended to fund its preparation or submission. No person other than amicus, its members, and its counsel made a contribution intended to fund the preparation or submission of this brief.

A. Breast Cancer Diagnoses In The United States Are Prevalent And Often Fatal
Breast cancer is the most common type of cancer among women in the United States and the second most deadly. 2 As of 2020, nearly 4 million people in the United States had been diagnosed with the disease. In 2023 alone, more than 300,000 additional people are likely to be diagnosed with invasive breast cancer in the United States, and the disease will cause more than 40,000 deaths. 3 Breast cancer affects not only the individual diagnosed, but also their families, caregivers, and loved ones. Given the prevalence of the disease and how devastating it can be, it has become part of daily life for far too many. Fortunately, preventive care measures can significantly reduce the risk of breast-cancer-caused deaths, as well as the risk that an early diagnosis advances to a more severe and costly case.

B. Medical Professionals Recommend Various Preventive Care Measures That Are Proven To Save Lives And Reduce Treatment Costs
There are various preventive care measures providers recommend to identify both the risk associated with developing breast cancer and early signs of the disease, therefore positioning patients to treat the disease as early as possible.
Early detection is crucial, as 98% of women diagnosed with breast cancer at the earliest stage live for five years or more, compared to about 31% of those diagnosed at the most advanced stage. 4 Early detection and treatment methods have improved over time. In fact, these improvements resulted in a 43% decline in the breast cancer death rate in the Ultimately, access to breast cancer preventive care measures results in more people living longer with lower costs of care.

C. The ACA's Preventive Care Coverage Expands Access To Life-Saving Care
Given the extraordinary benefits of preventive care, it is not surprising that the ACA includes a requirement obligating insurers and group health plans to cover certain breast-cancer-specific preventive care. 30 Specifically, insurers must 28 Blumen, Comparison of Treatment Costs for Breast Cancer, by Tumor Stage and Type of Service, 9 Am. Health Drug Benefits 23 (2016). 29 Id. 30 The ACA empowers certain agencies -including the Health Resources and Services Administration ("HRSA") and the Preventive Services Task Force ("USPSTF") -to determine which preventive care services must be covered. Komen understands that the district court found unconstitutional USPSTF's authority to prepare such guidelines and recommendations and found constitutional HRSA's authority to prepare such guidelines and recommendations, Braidwood Mgmt. Inc. v. Becerra, 627 F. Supp. 3d 624 (N.D. Tex. 2022) (ROA.1780-1821, and that Appellants and Appellees are challenging each holding, respectively. Komen does not have a position on the constitutional questions before the Court, and instead submits this brief to educate the Court on the benefits of preventive care for breast cancer and the consequences of the district court's decision.

II. THE DISTRICT COURT'S DECISION WOULD LIMIT ACCESS TO CARE, HARM TREATMENT EFFORTS, INCREASE COSTS, AND RISK LIVES
It is undeniable that the preventive care covered by the ACA has made a meaningful difference in the lives of people throughout the country. The remedy the district court ordered ensures that fewer people will have access to this care.
As a direct result, more people will die from breast cancer.