Breast Cancer Screening—Age-Stratified Benefits, Harms, and the Case for Risk-Based Shared Decision Making

Breast cancer screening guidelines have increasingly relied on expert opinion rather than robust clinical trial data to justify supplemental MRI in high-risk, non-BRCA1 women. While MRI improves cancer detection rates in average-risk populations, this detection advantage has not translated to demonstrated mortality reduction in randomized controlled trials, raising the question of whether earlier identification without survival benefit represents clinical progress or diagnostic expansion.The 2025 WISDOM trial provides landmark evidence that risk-stratified screening is superior in efficiency to age-based universal screening, with biennial mammography achieving non-inferior late-stage cancer detection for average-risk women (62% of population) while reducing false-positive burden by 25–30%.The article proposes actionable reforms: explicit evidence-grade labeling (evidence level vs. consensus strength), absolute risk quantification, shared decision-making templates for all NNS >50 scenarios, DCIS de-escalation through observation trials with risk stratification by grade, and implementation pathways accounting for health equity barriers. An evidence-guided orientation reframes screening away from fear of undetected cancers toward transparent, values-aligned medicine serving women's health interests.NOTE (Timing clarification—COMET DCIS Trial): Earlier text in this article referenced “2026–2027” as an estimated window for longer-term COMET outcomes. COMET’s published results to date report short-term outcomes; longer-term outcomes (including 5-, 7-, and 10-year follow-up analyses) remain pending, and publication timing is not guaranteed to map to specific calendar years. This clarification does not change the article’s conclusions or benefit–harm framing.