Risk-Adapted Breast Cancer Screening: Moving Beyond One-Size-Fits-All
- Dr Natalie Hutchins
- Jan 21
- 4 min read
Dr Natalie Hutchins
Over the past few years, breast cancer screening has become a frequent, and often polarised, topic on social media. Influencers highlighting the limitations of mammograms are widely shared, sometimes with the implication that because mammograms are not a perfect test, they should not be done at all and that other, non-approved forms of imaging, such as thermal imaging, should be used instead.
This conclusion is not only incorrect, it is potentially harmful.
Mammograms are imperfect, but they remain the only population-level screening tool shown to reduce breast cancer mortality. The real problem is that we are still using a one-size-fits-all, age-based approach in an era where we understand far more about individual risk.
A major new study now confirms what many breast specialists have been saying for years: screening works best when it is tailored to individual risk, rather than applied uniformly to everyone.
Why Mammograms Are Not a “Perfect Test”
No screening test is perfect, and mammography is no exception. It can miss cancers, particularly in younger women and those with dense breast tissue, and it can also detect abnormalities that turn out not to be cancer, leading to anxiety and biopsies that ultimately prove benign.
These limitations are often used online to argue for methods of screening that have not been approved for use without mammography alongside. But it seems the better solution lies in personalising screening so that the right women get the right test, at the right time, in the right way.
What Is Risk-Adapted (or Risk-Based) Breast Screening?
Risk-adapted screening means that your screening plan is determined by your individual risk profile, rather than your age alone.
Risk assessment can include:
Family history of breast and ovarian cancer
Personal reproductive history
Breast density
Lifestyle factors
Genetic information, including known high-risk genes and polygenic risk scores
Instead of every woman being offered the same test on the same schedule, screening intensity and modality are adjusted according to risk.
The WISDOM Trial: What Did It Show?
The WISDOM (Women Informed to Screen Depending on Measures of Risk) trial is the first large randomised study to properly test whether risk-based screening is a safe alternative to annual mammography.
The trial enrolled nearly 30,000 women aged 40–74 with no prior history of breast cancer. Participants were randomised into two groups:
One group received annual mammograms from age 40
The other group underwent formal risk assessment, with screening tailored accordingly
Depending on risk, women in the risk-based group were advised to:
Delay screening until age 50 if their risk was very low
Have mammograms every two years if their risk was average
Have annual mammograms if their risk was elevated
Undergo alternating MRI and mammography every six months if they were in the highest risk category
After a median follow-up of just over five years, the results were clear:
Cancer detection was the same in both groups
There was no increase in later-stage cancers in the risk-based group
Women at low risk had fewer mammograms overall
Screening intensity appropriately increased with rising risk
In other words, screening could safely be reduced for some women, while being intensified for those who needed it most—without compromising cancer outcomes
Risk adjusted screening
.
Why This Matters
This study confirms that breast cancer screening does not need to be an all-or-nothing approach. It can be smarter, safer, and more personalised.
Risk-adapted screening:
Avoids over-screening women at very low risk
Focuses resources on women at highest risk
Allows earlier use of MRI where it is most effective
Reduces unnecessary imaging without missing cancers
Knowing Your Risk Changes the Conversation
Understanding your personal breast cancer risk helps answer three key questions:
When should I start screening?
How often should I be screened?
What type of screening is most appropriate for me?
Validated risk calculators, such as the Tyrer–Cuzick model used in clinical practice and research, can provide a more nuanced estimate of risk. These tools are not diagnostic, and they are not meant to be used in isolation, but they are a valuable starting point.
If you calculate your risk, the next step should always be a conversation with your doctor about what that result means for you; not a unilateral decision to screen more, less, or not at all.
Key Take Away
Mammograms are not perfect, but they are not obsolete.
The future of breast cancer screening is about matching the screening strategy to the woman in front of us. The WISDOM trial provides strong evidence that risk-adapted screening is both safe and effective, and it marks an important step towards more personalised, evidence-based care.
As with so much in women’s health, nuance matters. And when we replace simplistic narratives with good data, women are better served.
Reference:
WISDOM Trial: Esserman LJ, Fiscalini AS, Naeim A, et al. Risk-Based vs Annual Breast Cancer Screening: The WISDOM Randomized Clinical Trial. JAMA. Published online December 12, 2025. doi:10.1001/jama.2025.24784
Further Resources:
For more information, watch our podcast on pelvic floor matters or listen to the conversation here. In this episode of The Women’s Handbook Podcast: How to Be a Woman, Dr Natalie Hutchins is joined by Dr Steven Tucker, a UCLA-trained medical oncologist with a deep interest in lifestyle medicine, metabolic health, digital health, and cancer prevention.
Together, they unpack what breast cancer risk actually means, how screening should be personalised rather than fear-driven, and where lifestyle, nutrition, fasting, and newer therapies genuinely fit, without abandoning evidence-based medicine.
This is a grounded, nuanced, and clinically honest conversation designed to cut through misinformation and empower women with clarity.
• Tyrer–Cuzick risk score
• NHS Breast Screening Programme (UK)https://www.nhs.uk/conditions/breast-cancer-screening/
• American Cancer Societyhttps://www.cancer.org/cancer/breast-cancer.html
• National Cancer Institute (US)https://www.cancer.gov/types/breast
• ASCO – American Society of Clinical Oncologyhttps://www.cancer.net/cancer-types/breast-cancer
• Breast Cancer Now (UK)https://breastcancernow.org
• Macmillan Cancer Supporthttps://www.macmillan.org.uk
• Breast Cancer Foundation Singaporehttps://www.bcf.org.sg
• World Cancer Research Fundhttps://www.wcrf.org
• NIH – Exercise & Cancer Outcomeshttps://www.cancer.gov/about-cancer/causes-prevention/risk/physical-activity
