Increased breast cancer death risk seen in women who miss first breast screening appointment

By Rebecca Jenkins

Women who do not attend their first breast screening appointment have a significantly increased risk of dying from breast cancer, which persists for 25 years, a large population cohort study finds.

Late-stage diagnosis was known to be more common in women who had not attended their latest breast screening appointment, the study authors wrote in the BMJ. But they said less was known about the long-term implications of women missing earlier appointments – specifically their first invited screening appointment.

Using linked data from multiple Swedish national registers with 25-years’ follow up, researchers analysed outcomes for 432,775 women who received invitations to the national breast screening program between 1991 and 2020 and were initially invited when they were aged 50 or 40 years.

Almost one-third of women invited to their first mammography screening (32.1%) did not participate, and this group was less likely to attend subsequent screenings and were more likely to have symptom-detected, advanced breast cancer diagnosed.

Compared with participants, women who did not participate had an odds ratio of 1.53 for stage III cancer and 3.61 for stage IV cancer.

Not attending the first screening was also associated with higher breast cancer mortality, with data showing a 25-year cumulative mortality of 9.9 per 1000 compared with 7 per 1000 participants, equating to a 40% increased risk.

‘By contrast, the 25-year breast cancer incidence was similar between groups (7.8% for participants versus 7.6% in non-participants), suggesting that the elevated mortality among first screening non-participants likely reflects delayed detection rather than increased incidence,’ the authors concluded. ‘These results emphasise the critical role of first screening attendance in predicting long term outcomes and provide new insights into how early non-participation may be linked to a trajectory of factors that adversely influence breast cancer prognosis.’

Associate Professor Sanjay Warrier, of the RPA Institute of Academic Surgery at The University of Sydney Central Clinical School, Sydney, called the study interesting and said the findings should be widely discussed.

‘Despite not showing a difference in breast cancer rates between first screen participants and non-participants, this study demonstrates a significant improvement in breast cancer-specific mortality and more advanced cancers for participants,’ he told Medicine Today.

Professor Warrier, who is also Academic Head at the Department of Breast Surgery, Chris O’Brien Lifehouse, Sydney, suggested that screening non-participants were likely presenting with larger tumours and more advanced tumours, leading to potentially increased treatments, but, importantly, fewer cures.

‘The study really highlights that screening is important, ongoing screening is important and we need to continue to be vigilant about attendance among our patients,’ he said.

The study’s publication coincided with the release of new Australian Institute of Health and Welfare (AIHW) data that showed more than 1.9 million women aged 50 to 74 years took part in the BreastScreen Australia program in 2023 to 2024. This number represented 52% of the target population and was an increase from the 1.8 million women (50% of the target population) who were screened in 2021 to 2022.

BMJ 2025; 390: e085029, and https://www.aihw.gov.au/reports/cancer-screening/breastscreen-australia-monitoring-report-2025/contents/summary.