-
Above-average risk | Personal hx invasive breast CA/DCIS/ALH/LCIS/ADH, confirmed/suspected gene mutation in pt or confirmed gene mutation in 1st-deg relative, hx chest radiation tx btwn ages 10-30, or ≥15% lifetime risk per FHx-based tool
High risk | Confirmed/suspected BRCA/other gene mutation in pt or confirmed BRCA/other gene mutation in 1st-deg relative, ≥20% lifetime risk per FHx-based tool, or hx chest radiation tx btwn ages 10-30 Confirmed/suspected BRCA/other gene mutation in pt or confirmed BRCA/other gene mutation in 1st-deg relative, or ≥20% lifetime risk per FHx-based tool If high risk1,2 due to BRCA/other gene mutation3 in self/1st-deg relative, assess with appropriate brief familial risk assessment tool; if (+) result, refer for genetic counseling (AAFP,4 NCCN,2 USPSTF5) If high lifetime risk1,2 ≥20% due (largely) to FHx: MRI + mammography screen (tomosynthesis guidance varies) - Annual breast MRI + mammogram recommended;6-9 ACR6 rates tomosynthesis equivalent w/ mammography, NCCN8 includes tomosynthesis as a consideration. ACR6 specifies MRI (w/ & w/o contrast). Use US if MRI not an option (ACOG,9 ACR10). Use facility capable of MRI-guided bx (NCCN11)
- Start screening: @ 30 yo for most pts (ACS7), 25-30 yo (ACR6); consider shared decision-making, as data limited (ACS7); start annual mammogram screening 10y prior to youngest family member’s age at time of breast CA dx, but not <30 yo (ACR,6 NCCN11) and not before age 25 for MRI (NCCN11)
- If BRCA(+): NCCN includes age-based guidance;12 consider risk reduction strategies (NCCN11)
- Stop screening: Continue as long as pt in good health (ACS7) and life expectancy exceeds 5-7y (ACR13)
Clinical breast exam (CBE)14 guidance varies: - If ≥20% lifetime risk per FHx-based tool: Recommend clinical encounter14 q6-12mo starting from when increased risk first identified, but not before 21 yo (NCCN11); ACOG9,15 recommends q6mo
- If BRCA(+): Examine q6-12mo starting @ 25 yo (NCCN12); ACOG9,15 recommends q6mo
- ACS7 doesn’t recommend CBE; NCI16 states evidence insufficient
Breast self-awareness and breast self-exam (BSE) guidance varies: - Recommend breast awareness (ACS,1 ACOG,9 NCCN11).
- If BRCA(+): Start breast awareness @ 18 yo, per NCCN12
- BSE results in more bx and benign lesion dx, per NCI.16 However, ACOG9 recommends BSE instruction for BRCA(+) pts, pts w/ confirmed BRCA/other gene mutation in 1st-deg relative, or pts w/ lifetime risk ≥20% based on FHx model
Footnotes 1 ACS 2019.High risk for breast CA includes:
• Lifetime breast CA risk of ~20%-25% or greater per tools based mainly on FHx (eg, Claus model)
• Known BRCA(+) (based on genetic testing) or untested pt w/ 1st-deg relative BRCA(+)
• RT to chest when 10-30 yo
• Self/1st-deg relative w/ Li-Fraumeni/Cowden/BRR syndromes.
Increased risk for breast CA includes:
• Moderately increased risk: Pts w/ lifetime risk 15%-19% per tools based mainly on FHx
• Increased risk: Personal hx breast CA/DCIS/LCIS/ALH/ADH; dense breasts (extremely or heterogeneously) on mammography.
American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 10/22/19.
2 [NCCN-2A] NCCN 2019. Increased breast CA risk includes:
• Prior hx breast CA
• 5-yr risk of invasive breast CA ≥1.7% in pts ≥35 yo (Gail Model)
• ≥20% lifetime risk (per models mainly dependent on FHx: Claus, BRCAPRO, Tyrer-Cuzick)
• >20% lifetime risk due to LCIS/ALH/ADH
• Thoracic RT btwn ages 10-30 yo
• Pedigree suggestive/known for genetic predisposition.
NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
3 NCCN 2019. Examples of high-penetrance mutations: BRCA1/2, ATM, BARD1, CHEK2, PALB2, TP53, PTEN, STK11, and CDH1. NCCN Clinical Practice Guidelines in Oncology. Genetic/Familial High-Risk Assessment: Breast and Ovarian. Version 3.2019. Online Accessed 10/15/19.
4 AAFP 2016. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
PCPs should screen women who have family members w/ breast, ovarian, tubal, or peritoneal CA w/ a screening tool designed to identify FHx that may be associated w/ increased risk for BRCA1/2 mutations. Women w/ positive screening results should have genetic counseling and, if indicated, BRCA testing [AAFP-B]. AAFP recommends against routine genetic counseling or BRCA testing for women whose FHx is not associated w/ increased risk for BRCA1/2 mutations [AAFP-D].
5 USPSTF 2019. Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: U.S. Preventive Services Task Force Recommendation Statement. Online Accessed 10/15/19.
• If FHx may be assoc w/ increased risk for potentially harmful BRCA mutations: screen w/ appropriate brief familial risk tool, then if (+), refer for genetic counseling. If indicated post counseling, then BRCA test. [USPSTF-B] Don’t routinely recommend genetic counseling or genetic testing if FHx not associated w/ increased risk for BRCA. [USPSTF-D]
• FHx factors assoc w/ increased likelihood of potentially harmful BRCA mutations: breast CA dx in family member <50 yo, FHx bilateral breast CA, FHx breast and ovarian CA, breast CA in ≥1 male family member, multiple breast CA cases in family, ≥1 family member w/ 2 primary BRCA-related CA types, and Ashkenazi Jewish ethnicity.
Risk stratification tools to determine need for genetic counseling: Ontario Family History Assessment Tool, Manchester Scoring System, Referral Screening Tool, Pedigree Assessment Tool, FHS-7, International Breast Cancer Intervention Study instrument (Tyrer-Cuzick), and brief versions of BRCAPRO. However, USPSTF notes that general breast CA risk assessment models (eg, the National Cancer Institute Breast Cancer Risk Assessment Tool, which is based on the Gail model) aren’t designed to identify BRCA-related cancer risk and shouldn’t be used for this purpose.
6 [ACR-9] ACR 2017. ACR Appropriateness Criteria. Breast Cancer Screening. PDF
7 ACS 2016. American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 10/22/19.
8 [NCCN-2A] NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
9 ACOG 2011. Practice Bulletin Number 122. Breast Cancer Screening. Obstet Gynecol. 2011 Aug;118(2 Pt 1):372-382. PubMed® abstract
10 [ACR-6] ACR 2017. ACR Appropriateness Criteria. Breast Cancer Screening. PDF
11 [NCCN-2A] NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
If hx chest radiation btwn ages 10-30, start screening 10y after RT, but not before 30 yo for mammogram and not before age 25 yo for MRI; clinical encounter starting 10y after RT; annually if current age <25 yo; q6-12mo if ≥25 yo.
12 [NCCN-2A] NCCN 2019.
BRCA(+): Breast awareness starting age 18 yo; start clinical breast exam q6-12mo @ age 25 yo.
Screening:
• 25-29 yo: annual MRI w/ contrast preferred (mammogram w/ consideration of tomosynthesis, only if MRI unavailable). If family member dx w/ breast CA <30 yo, individualize screening
• 30-75 yo: annual mammogram plus consideration of tomosynthesis and MRI w/ contrast
• >75 yo: individualize screening
If hx chest radiation btwn ages 10-30, clinical encounter starting 10y after RT; annually if current age <25 yo; q6-12mo if ≥25 yo.
NCCN Clinical Practice Guidelines in Oncology. Genetic/Familial High-Risk Assessment: Breast and Ovarian. Version 3.2019. Online Accessed 10/15/19.
13 ACR 2018. ACR Practice Parameter for the Performance of Screening and Diagnostic Mammography. Revised 2018 (Resolution 35). PDF
14 [NCCN-2A] NCCN 2019. CBE is considered as part of the clinical “encounter,” along w/ ongoing risk assessment and risk reduction counseling. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
15 [ACOG-C] ACOG 2017. CBE is recommended when evaluating high-risk women and women w/ sx. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/15/19.
16 NCI 2019. Breast Cancer Screening–for health professionals. Updated: 9/26/19. Online Accessed 10/22/19.
Clinical breast exam:
• Benefits. Current evidence insufficient to assess additional benefits/harms of CBE. The single RCT comparing high-quality CBE w/ screening mammography showed equivalent benefit. CBE accuracy in community setting might be lower than in the RCT.
• Harms. False(+) w/ additional tests, anxiety. Specificity in women 50-59 yo: 88% to 99%, yielding false(+) rate of 1%-12%. False(-) w/ false reassurance, potential dx delay. Of women w/ CA, 17%-43% have neg CBE. Sensitivity higher w/ longer duration and higher quality exam by trained personnel.
Breast self-exam:
• Benefits. Compared w/ no screening, it hasn’t been shown to reduce breast CA mortality.
• Harms. Based on solid evidence, formal instruction + encouragement to perform BSE leads to more breast bx and dx of more benign breast lesions. Bx rate was 1.8% among study population vs 1.0% among the controls.
Hx chest radiation tx btwn ages 10-30 If high risk1,2 due to hx chest radiation tx when 10-30 yo: MRI + mammography screen (tomosynthesis guidance varies) - Annual breast MRI + mammogram recommended;3-6 ACR3 rates tomosynthesis equivalent w/ mammography, NCCN5 includes tomosynthesis as a consideration. ACR3 specifies MRI (w/ & w/o contrast). Use US if MRI not an option (ACOG,6 ACR7). Use facility capable of MRI-guided bx (NCCN8)
- Start screening: 8y after RT, but not before 25 yo (ACR3); NCCN8 says start screening 10y after RT, but not before 30 yo (for mammogram) and not before 25 yo (for MRI)
- Stop screening: Continue as long as pt in good health (ACS4 and life expectancy exceeds 5-7y (ACR9)
Clinical breast exam (CBE)10 guidance varies: - Clinical encounter10 starting 10y after RT; annually, if current age <25 yo; q6-12mo, if ≥25 yo (NCCN,8 ACOG6,11)
- ACS4 doesn’t recommend CBE; NCI12 states evidence insufficient
Breast self-awareness and breast self-exam (BSE) guidance as follows: - Recommend breast self-awareness (ACS,1 ACOG,6 NCCN8)
- BSE results in more bx and benign lesion dx, per NCI12
Footnotes 1 ACS 2019.High risk for breast CA includes:
• Lifetime breast CA risk of ~20%-25% or greater per tools based mainly on FHx (eg, Claus model)
• Known BRCA(+) (based on genetic testing) or untested pt w/ 1st-deg relative BRCA(+)
• RT to chest when 10-30 yo
• Self/1st-deg relative w/ Li-Fraumeni/Cowden/BRR syndromes.
Increased risk for breast CA includes:
• Moderately increased risk: Pts w/ lifetime risk 15%-19% per tools based mainly on FHx
• Increased risk: Personal hx breast CA/DCIS/LCIS/ALH/ADH; dense breasts (extremely or heterogeneously) on mammography.
American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 10/22/19.
2 [NCCN-2A] NCCN 2019. Increased breast CA risk includes:
• Prior hx breast CA
• 5-yr risk of invasive breast CA ≥1.7% in pts ≥35 yo (Gail Model)
• ≥20% lifetime risk (per models mainly dependent on FHx: Claus, BRCAPRO, Tyrer-Cuzick)
• >20% lifetime risk due to LCIS/ALH/ADH
• Thoracic RT btwn ages 10-30 yo
• Pedigree suggestive/known for genetic predisposition.
NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
3 [ACR-9] ACR 2017. ACR Appropriateness Criteria. Breast Cancer Screening. PDF
4 ACS 2016. American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 10/22/19.
5 [NCCN-2A] NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
6 ACOG 2011. Practice Bulletin Number 122. Breast Cancer Screening. Obstet Gynecol. 2011 Aug;118(2 Pt 1):372-382. PubMed® abstract
7 [ACR-6] ACR 2017. ACR Appropriateness Criteria. Breast Cancer Screening. PDF
8 [NCCN-2A] NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
9 ACR 2018. ACR Practice Parameter for the Performance of Screening and Diagnostic Mammography. Revised 2018 (Resolution 35). PDF
10 [NCCN-2A] NCCN 2019. CBE is considered as part of the clinical “encounter,” along w/ ongoing risk assessment and risk reduction counseling. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
11 [ACOG-C] ACOG 2017. CBE is recommended when evaluating high-risk women and women w/ sx. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/15/19.
12 NCI 2019. Breast Cancer Screening–for health professionals. Updated: 9/26/19. Online Accessed 10/22/19.
Clinical breast exam:
• Benefits. Current evidence insufficient to assess additional benefits/harms of CBE. The single RCT comparing high-quality CBE w/ screening mammography showed equivalent benefit. CBE accuracy in community setting might be lower than in the RCT.
• Harms. False(+) w/ additional tests, anxiety. Specificity in women 50-59 yo: 88% to 99%, yielding false(+) rate of 1%-12%. False(-) w/ false reassurance, potential dx delay. Of women w/ CA, 17%-43% have neg CBE. Sensitivity higher w/ longer duration and higher quality exam by trained personnel.
Breast self-exam:
• Benefits. Compared w/ no screening, it hasn’t been shown to reduce breast CA mortality.
• Harms. Based on solid evidence, formal instruction + encouragement to perform BSE leads to more breast bx and dx of more benign breast lesions. Bx rate was 1.8% among study population vs 1.0% among the controls.
Mod/Intermediate risk | 15%-20% lifetime risk; prior hx of invasive breast CA/DCIS/LCIS/ALH/ADH; no confirmed/suspected gene mutation nor hx chest radiation tx btwn ages 10-30 Screen mod/increased-risk1,2 pts w/ mammography (tomosynthesis guidance varies); discuss benefits3 & harms.4 Adjunctive MRI guidance varies - If hx breast CA: annual mammography (ACR,5 NCCN6); ACR rates tomosynthesis equivalent w/ mammography5 as usually appropriate and considers that adjunctive MRI7 (w/ and w/o contrast) may be appropriate. However, ACS8 considers insufficient evidence for adjunctive MRI for breast CA pts. If s/p breast-conserving surgery, recommend post-tx mammogram 1y after initial mammogram—at least 6mo after RT completion—then annually (ASCO,9 NCCN10); if DCIS w/ breast conserved, NCCN6 additionally recommends mammogram @ 6-12mo after breast conservation tx. NCCN10 doesn't consider routine imaging of reconstructed breast to be indicated
- If LCIS/ALH/ADH: annual mammogram (ACR,5 NCCN,6 ACOG11); ACR5 rates tomosynthesis equivalent w/ mammography; NCCN12 specifies not starting mammography <30 yo and to consider tomosynthesis. Adjunctive MRI (w/ and w/o contrast) is usually appropriate, per ACR;7 consider annual MRI (not starting <25 yo) per NCCN;13 however, insufficient evidence for MRI, per ACS.8 Consider risk reduction strategies (NCCN12)
- If lifetime breast CA risk 15%-20% (per tool based mainly on FHx): ACR recommends annual mammography (or tomosynthesis);5 adjunctive MRI (w/ and w/o contrast) is considered usually appropriate7
- If dense breasts (BI-RADS C/D): insufficient evidence on alt/supplemental approaches in pts w/o other risk factors (ACOG,14 ACS8); NCCN15 recommends counseling re: risk/benefits of supplemental screening. Massachusetts approach:16 Consider adjunct MRI/US, in addition to mammogram; ACR17 considers supplemental US an option
Clinical breast exam (CBE)18 guidance varies: - If hx breast CA: for invasive cancer, physical exam 1-4x per yr x5y, then annually;10 for DCIS, physical exam q6-12mo x5y, then annually (NCCN10). ASCO9 recommends physical exam q3-6mo for first 3y, then q6-12mo for yrs 4 and 5, then annually
- If LCIS/ALH/ADH: CBE (encounter) q6-12mo (NCCN,12 ACOG11,19)
- ACS20 doesn't recommend CBE; NCI21 states evidence insufficient
Breast self-awareness and breast self-exam (BSE) guidance varies: - Recommend breast self-awareness (ACS,20 ACOG,11 NCCN12)
- BSE leads to more bx and benign lesion dx, per NCI;22 however, ACOG11 recommends BSE instruction for pts w/ certain breast bx results (eg, atypical hyperplasia, LCIS)
Footnotes 1 ACS 2019.
High risk for breast CA includes:
• Lifetime breast CA risk of ~20%-25% or greater per tools based mainly on FHx (eg, Claus model)
• Known BRCA(+) (based on genetic testing) or untested pt w/ 1st-deg relative BRCA(+)
• RT to chest when 10-30 yo
• Self/1st-deg relative w/ Li-Fraumeni/Cowden/BRR syndromes.
Increased risk for breast CA includes:
• Moderately increased risk: Pts w/ lifetime risk 15%-20% per tools based mainly on FHx
• Increased risk: Personal hx breast CA/DCIS/LCIS/ALH/ADH; dense breasts (extremely or heterogeneously) on mammography.
American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 10/15/19.
2 [NCCN-2A] NCCN 2019. Increased breast CA risk includes:
• Prior hx breast CA
• 5-yr risk of invasive breast CA ≥1.7% in pts ≥35 yo (Gail Model)
• ≥20% lifetime risk (per models mainly dependent on FHx: Claus, BRCAPRO, Tyrer-Cuzick)
• >20% lifetime risk due to LCIS/ALH/ADH
• Thoracic RT btwn ages 10-30 yo
• Pedigree suggestive/known for genetic predisposition.
NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
3 NCI 2019. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Mammography benefits:
• Screening mammography reduces breast CA-specific mortality for women 60-69 yo (solid evidence) and for women 50-59 yo (fair evidence) based on RCTs
• Recent pop studies question the benefits of screened populations who participate in screening for longer duration
• Women 30-49 yo: 1,904 women needed to prevent 1 breast CA death
• Women 50-59 yo: 1,339 women needed to prevent 1 breast CA death
• Women 60-69 yo: 377 women needed to prevent 1 breast CA death
• The 25-yr f/u from Canadian National Breast Screening Study (CNBSS) RCT completed in 2014, showed no mortality benefit assoc w/ mammography screening
4 NCI 2019. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Mammography harms:
• Over-dx + tx of insignificant cancers that wouldn't have caused sx or death. Certain studies find that btwn 20% and 50% of screen-detected breast CA are over-dx based on pt age, life expectancy, and tumor type (ductal carcinoma in situ and/or invasive).
• False(+) w/ additional tests, anxiety. 10% of women will be recalled from each screening exam for further tests; only 5 of 100 recalled will have CA. Approx 50% of women screened annually for 10y in US will experience a false(+), of whom 7%-17% will have bx. Additional testing less likely when prior mammograms available for comparison.
• False(-) w/ false security, potential dx delay. 6% to 46% of women w/ invasive CA have neg mammogram, esp if young, dense breasts, or mucinous, lobular, or rapidly growing CA.
Radiation-induced breast CA: Radiation-induced mutations can cause breast CA, but w/ radiation doses higher than those used in a single mammography exam. Dose for typical 2-view mammogram is extremely unlikely to cause CA. Theoretically, annual mammogram in women aged 40-80 yrs may cause up to 1 breast CA per 1,000 women.
5 [ACR-9] ACR 2017. ACR Appropriateness Criteria. Breast Cancer Screening. PDF
6 [NCCN-2B] NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. Version 3.2019. Online Accessed 10/15/19.
7 [ACR-7] ACR 2017. If pt has 15%-20% lifetime risk, personal Hx breast CA, LCIS, ALH, or ADH: screening MRI (w/ and w/o contrast) is usually appropriate; investigations are ongoing, yet recent reports support adjunctive screening MRI in pts w/ personal hx breast CA or lobular neoplasia. ACR Appropriateness Criteria. Breast Cancer Screening. PDF
8 ACS 2019. American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 2/8/17.
9 ASCO 2013. Breast Cancer Follow-Up and Management After Primary Treatment: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2013 Mar 1;31(7):961-5. PDF
10 [NCCN-2A] NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. Version 3.2019. Online Accessed 10/15/19.
11 ACOG 2011. Practice Bulletin Number 122. Breast Cancer Screening. Obstet Gynecol. 2011 Aug;118(2 Pt 1):372-382. PubMed® abstract
12 [NCCN-2A] NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 3.2019. Online Accessed 10/15/19.
• If 5-yr Gail Model risk of invasive breast CA ≥1.7% (pts ≥35 yo): annual mammogram, once identified as increased risk by Gail Model; consider tomosynthesis and risk reduction strategies; clinical encounter q6-12mo starting from when increased risk identified.
• If hx of LCIS or ADH/ALH and >20% lifetime risk: clinical encounter q6-12mo starting @ LCIS or ADH/ALH dx.
13 NCCN 2019. Based on emerging evidence. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
14 ACOG 2015. Modestly increased breast CA risk, reduced mammography sensitivity seen w/ dense breasts, including BI-RADS 3 and 4, yet current evidence doesn’t show meaningful benefits w/ supplemental/alternative tests (US, MRI, tomosynthesis, thermography) in pts w/o other risk factors. Management of Women With Dense Breasts Diagnosed by Mammography. Committee Opinion Number 625, March 2015. PDF
15 [NCCN-2A] NCCN 2019. Mammographically dense breast tissue assoc w/ increased risk for breast CA and limits mammography sensitivity. Consider pts on risk/benefits of supplemental screening:
• Full-field digital mammography appears to offer benefit in women w/ dense breasts
• Tomosynthesis can ↑detection and ↓call backs, but most studies involved double-dose radiation (2-D reconstruction can ↓doses)
• US. Routine adjunctive use for screening not recommended for dense breasts; may ↑detection rates but also ↑recalls and benign breast bx
• Molecular imaging (gamma, sestamibi, positron emission). Routine use in dense breasts isn’t supported by current evidence
• Thermography/ductal lavage isn’t supported by current evidence.
NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
16 Based on evidence-based management algorithm from multidisciplinary expert panel, for women w/ 15%-20% lifetime risk of breast CA (though Gail Model not recommended for risk assessment) and dense breasts, decision for adjunctive MRI/US to be accompanied by discussion of possible false-positives, possible benefits, plus cost. Breast Cancer Screening in the Era of Density Notification Legislation: Summary of 2014 Massachusetts Experience and Suggestion of an Evidence-based Management Algorithm by Multidisciplinary Expert Panel. Breast Cancer Res Treat. 2015 Sep;153(2):455-64. PDF
17 ACR 2017. While supplemental US is an option, it has a high false(+) rate and is time-consuming. ACR Appropriateness Criteria. Breast Cancer Screening. PDF
18 [NCCN-2A] NCCN 2019. CBE is considered as part of the clinical “encounter,” along w/ ongoing risk assessment and risk reduction counseling. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
19 [ACOG-C] ACOG 2017. CBE is recommended when evaluating high-risk women and women w/ sx. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/15/19.
20 ACS 2019. American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 10/22/19.
21 NCI 2019. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Clinical breast exam:
• Benefits. Current evidence insufficient to assess additional benefits/harms of CBE. A single RCT comparing high-quality CBE w/ screening mammography showed equivalent benefit. CBE accuracy in community setting might be lower than in the RCT.
• Harms. False(+) w/ additional tests, anxiety. Specificity in women 50-59 yo: 88% to 99%, yielding false(+) rate of 1%-12%. False(-) w/ false reassurance, potential dx delay. Of women w/ CA, 17%-43% have neg CBE. Sensitivity higher w/ longer duration and higher quality exam by trained personnel.
22 NCI 2019. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Breast self-exam:
• Benefits. Compared w/ no screening, it hasn’t been shown to reduce breast CA mortality.
• Harms. Based on solid evidence, formal instruction + encouragement to perform BSE leads to more breast bx and dx of more benign breast lesions. Bx rate was 1.8% among study population vs 1.0% among the controls.
-
Average risk | Lifetime risk <15% per FHx-based tool, no personal hx breast CA/DCIS/LCIS/ALH/ADH, no confirmed/suspected gene mutation in pt nor confirmed gene mutation in 1st-deg relative, no hx chest radiation tx btwn ages 10-30
Screening mammography generally not recommended for average-risk1-3 pts <40 yo (ACS,4 NCI,5 USPSTF,6 ACOG7). ACS1 recommends against MRI screening for women whose lifetime risk of breast CA is <15%. Breast exam guidance varies Clinical breast exam (CBE)8 guidance varies: - CBE not recommended d/t lack of evidence (ACP,9 ACS10); insufficient evidence to assess benefits/harms (NCI,11 USPSTF6)
- However, NCCN12 recommends CBE (encounter8) q1-3y for pts 25-39, as does ACOG13 in the context of shared, informed decision-making approach
Breast self-exam (BSE) not recommended: - BSE not recommended d/t lack of evidence for clear benefit (ACOG,14 ACS15) and risk of harm from false-positives (ACOG14)
- NCCN16 cites RCT showing no effect on breast CA mortality
- AAFP17 recommends against teaching BSE; BSE results in more bx and benign lesions dx (NCI18)
Breast self-awareness recommended: - Counsel average-risk women to become familiar w/ normal look/feel of their breasts and report changes to clinicians (NCCN,12 ACOG,19 ACS,15 USPSTF20)
Footnotes 1 ACS 2019. High risk for breast CA includes:
• Lifetime breast CA risk of ~20%-25% or greater per tools based mainly on FHx (eg, Claus model)
• Known BRCA(+) (based on genetic testing) or untested pt w/ 1st-deg relative BRCA(+)
• RT to chest when 10-30 yo
• Self/1st-deg relative w/ Li-Fraumeni/Cowden/BRR syndromes.
Increased risk for breast CA includes:
• Moderately increased risk: Pts w/ lifetime risk 15%-20% per tools based mainly on FHx
• Increased risk: Personal hx breast CA/DCIS/LCIS/ALH/ADH; dense breasts (extremely or heterogeneously) on mammography.
American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 10/15/19.
2 [NCCN-2A] NCCN 2019. Increased breast CA risk includes:
• Prior hx breast CA
• 5-yr risk of invasive breast CA ≥1.7% in pts ≥35 yo (Gail Model)
• ≥20% lifetime risk (per models mainly dependent on FHx: Claus, BRCAPRO, Tyrer-Cuzick)
• >20% lifetime risk due to LCIS/ALH/ADH
• Thoracic RT btwn ages 10-30 yo
• Pedigree suggestive/known for genetic predisposition.
NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
3 NCI 2019. Howlader N, et al. SEER Cancer Statistics Review, 1975-2016. National Cancer Institute. Updated 9/5/19. Online Accessed 10/22/19. Risk that a woman will be diagnosed with breast CA during the next 10y, starting at the following ages:
• Age 30: 0.48% (1 in 208)
• Age 40: 1.53% (1 in 65)
• Age 50: 2.38% (1 in 42)
• Age 60: 3.54% (1 in 28)
• Age 70: 4.07% (1 in 25)
Also available: Ethnicity Table.
4 [ACS-S] ACS 2015. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update from the American Cancer Society. JAMA. 20 Oct 2015;314(15)1599-1614. Full-text accessed 2/8/17. PubMed® abstract
5 NCI 2019. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
6 [USPSTF-C] USPSTF 2016. Breast Cancer: Screening. Online Accessed 10/15/19.
7 [ACOG-A] ACOG 2017. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/22/19.
8 [NCCN-2A] NCCN 2019. CBE is considered as part of the clinical “encounter,” along w/ ongoing risk assessment and risk reduction counseling. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
9 ACP 2019. Guidance Statement 4. Qaseem A, et al. Clinical Guidelines. Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians. Ann Intern Med. 2019; M18-2147. Online Accessed 6/25/19.
10 [ACS-Q] ACS 2015. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update from the American Cancer Society. JAMA. 20 Oct 2015; 314(15)1599-1614. PubMed® abstract Full text accessed 2/8/17.
11 NCI 2019. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Clinical breast exam:
• Benefits. Current evidence insufficient to assess additional benefits/harms of CBE. The single RCT comparing high-quality CBE w/ screening mammography showed equivalent benefit. CBE accuracy in community setting might be lower than in the RCT.
• Harms. False(+) w/ additional tests, anxiety. Specificity in women 50-59 yo: 88% to 99%, yielding false(+) rate of 1%-12%. False(-) w/ false reassurance, potential dx delay. Of women w/ CA, 17%-43% have neg CBE. Sensitivity higher w/ longer duration and higher quality exam by trained personnel.
12 [NCCN-2A] NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
13 [ACOG-C] ACOG 2017. CBE may be offered in context of shared, informed decision-making, recognizing uncertainty of benefits/harms beyond screening mammography. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/15/19.
14 [ACOG-B] ACOG 2017. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/15/19.
15 ACS 2016. American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 10/22/19.
16 NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
17 [AAFP-D] AAFP 2016. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
18 NCI 2019. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Breast self-exam:
• Benefits. Compared w/ no screening, it hasn’t been shown to reduce breast CA mortality.
• Harms. Based on solid evidence, formal instruction + encouragement to perform BSE leads to more breast bx and dx of more benign breast lesions. Bx rate was 1.8% among study population vs 1.0% among the controls.
19 [ACOG-C] ACOG 2017. Educate on s/sx of breast CA; advise pts to notify clinicians for pain, mass, new-onset nipple discharge, or redness. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/15/19.
20 USPSTF 2016. Siu AL, et al. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(4):279-296. Online Accessed 9/22/20.
Mammography starting in 40s for average-risk1-3 pts recommended by several groups; guidance varies on tomosythensis4 and breast exam
- USPSTF 2023 draft: Biennial screening recommended for all women starting at age 40 (B grade)
- Individualize mammography recommendations for women <50 (AAFP,5 USPSTF 6). Those who place higher value on potential benefit vs harms may choose to begin biennial screening mammography (ACP,7 USPSTF6)
- ACP7 concludes potential harms of screening for breast CA w/ mammography outweigh benefits in most average-risk women <50 yo. Initiate screening discussions at 40 yo: factor risk profile, pt preferences, and values on benefits/harms. May offer biennial mammography for those who prefer to be screened, after careful discussion of benefits8/harms9,10 (ACP7)
- ACOG11 recommends offering mammography starting age 40; if pt desires, initiate annual or biennial screening at ages 40-49 after counseling; screen transgender men as long as breast tissue present (review op records to ensure mastectomy, not reduction, was performed); don’t screen transgender women until age 50 & ≥5y on feminizing hormones12
- ACS recommends annual mammography screen beginning 45 yo,13 w/ choice to screen annually offered at ages 40-44;14 consider individual risks/benefits
- NCCN15 and ACR16 recommend annual mammography
- Modalities ACR16 rates tomosynthesis equivalent to mammography; NCCN4 includes tomosynthesis as a consideration. However, AAFP17 and USPSTF18 consider tomosynthesis evidence to be insufficient. US breast may be appropriate (ACR19); however, adjunctive screening MRI, FDG-PEM, Tc-99m sestamibi MBI not recommended/insufficient evidence (ACR19); ACS1 recommends against breast MRI screening for women whose lifetime risk of breast CA is <15%.
- If dense breasts: Alternative tests not recommended in asymptomatic women w/o additional risk factors (ACOG20); NCCN21 recommends counseling re: risks vs benefits of supplemental screening; insufficient evidence cited for US, MRI, digital breast tomosynthesis (AAFP,17 USPSTF22)
Clinical breast exam (CBE)23 guidance varies: - CBE not recommended d/t lack of evidence (ACP,24 ACS14); insufficient evidence to assess benefits/harms (AAFP,25 NCI,26 USPSTF22)
- However, NCCN4 recommends annual CBE (encounter23) beginning age 40, as does ACOG27 in context of shared, informed decision-making approach
Breast self-exam (BSE) not recommended: - BSE not recommended d/t lack of evidence (ACOG,28 ACS29); risk of harm from false-positives (ACOG28)
- NCCN30 cites RCT showing no effect on breast CA mortality
- AAFP31 recommends against teaching BSE; BSE results in more bx and benign lesion dx (NCI32)
Breast self-awareness recommended: - Counsel average-risk women to become familiar w/ normal look/feel of their breasts and report changes to clinicians (NCCN,4 ACOG,33 ACS,29 USPSTF34)
Footnotes 1 ACS 2019.
High risk for breast CA includes:
• Lifetime breast CA risk of ~20%-25% or greater per tools based mainly on FHx (eg, Claus model)
• Known BRCA(+) (based on genetic testing) or untested pt w/ 1st-deg relative BRCA(+)
• RT to chest when 10-30 yo
• Self/1st-deg relative w/ Li-Fraumeni/Cowden/BRR syndromes.
Increased risk for breast CA includes:
• Moderately increased risk: Pts w/ lifetime risk 15%-20% per tools based mainly on FHx
• Increased risk: Personal hx breast CA/DCIS/LCIS/ALH/ADH; dense breasts (extremely or heterogeneously) on mammography.
American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 10/15/19.
2 NCCN 2019. Increased breast CA risk includes:
• Prior hx breast CA
• 5-yr risk of invasive breast CA ≥1.7% in pts ≥35 yo (Gail Model)
• ≥20% lifetime risk (per models mainly dependent on FHx: Claus, BRCAPRO, Tyrer-Cuzick)
• >20% lifetime risk due to LCIS/ALH/ADH
• Thoracic RT btwn ages 10-30 yo
• Pedigree suggestive/known for genetic predisposition.
NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
3 NCI 2019. Howlader N, et al. SEER Cancer Statistics Review, 1975-2016. National Cancer Institute. Updated 9/5/19. Online Accessed 10/22/19.
Risk that a woman will be diagnosed with breast CA during the next 10y, starting at the following ages:
• Age 30: 0.48% (1 in 208)
• Age 40: 1.53% (1 in 65)
• Age 50: 2.38% (1 in 42)
• Age 60: 3.54% (1 in 28)
• Age 70: 4.07% (1 in 25)
Also available: Ethnicity Table.
4 [NCCN-2A] NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
5 [AAFP-C] AAFP 2016. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
6 [USPSTF-C] USPSTF 2016. Breast Cancer: Screening. Online Accessed 10/15/19.
Decision to start screening prior to age 50 should be individualized. For women at average risk, most benefit of mammography results from biennial screening at ages 50 to 74. Women 60 to 69 yo most likely to avoid breast CA death through screening. Though screening in women 40 to 49 yo may ↓risk for breast CA death, # of deaths averted is smaller vs in older women and # of false-positives/unnecessary bx is larger. In addition, all women undergoing regular screening at risk for “over-dx” (dx & tx of noninvasive and invasive breast CA that would otherwise not have become a threat, or even apparent, during pt’s lifetime). Women w/ a parent/sibling/child w/ breast CA are at higher risk and thus may benefit more from beginning screening in their 40s.
7 ACP 2019. Guidance Statement 1. Qaseem A, et al. Clinical Guidelines. Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians. Ann Intern Med. 2019; M18-2147. Online Accessed 6/25/19.
8 NCI 2019. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Mammography benefits:
• Screening mammography reduces breast CA-specific mortality for women 60-69 yo (solid evidence) and for women 50-59 yo (fair evidence) based on RCTs
• Recent pop studies question the benefits of screened populations who participate in screening for longer duration
• Women 30-49 yo: 1,904 women needed to prevent 1 breast CA death
• Women 50-59 yo: 1,339 women needed to prevent 1 breast CA death
• Women 60-69 yo: 377 women needed to prevent 1 breast CA death
• The 25-yr f/u from Canadian National Breast Screening Study (CNBSS) RCT, completed in 2014, showed no mortality benefit assoc w/ mammography screening.
9 NCI 2016. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Mammography harms:
• Over-dx + tx of insignificant cancers that would not have caused sx or death. Certain studies find that btwn 20% and 50% of screen-detected breast CA are over-dx based on pt age, life expectancy, and tumor type (ductal carcinoma in situ and/or invasive).
• False(+) w/ additional tests, anxiety. 10% of women will be recalled from each screening exam for further tests; only 5 of 100 recalled will have CA. Approx 50% of women screened annually for 10y in US will experience a false(+), of whom 7%-17% will have bx. Additional testing less likely when prior mammograms available for comparison.
• False(-) w/ false security, potential dx delay. 6% to 46% of women w/ invasive CA have neg mammogram, esp if young, dense breasts, or mucinous, lobular, or rapidly growing CA.
Radiation-induced breast CA: Radiation-induced mutations can cause breast CA, but w/ radiation doses higher than those used in a single mammography exam. Dose for typical 2-view mammogram is extremely unlikely to cause CA. Theoretically, annual mammogram in women aged 40-80 yrs may cause up to 1 breast CA per 1,000 women.
10 USPSTF 2016. Harms from screening: False-positive results which can lead to psychological harms, additional testing, invasive f/u; over-dx/tx of CA that would never become a threat to a woman’s health or become clinically apparent during a woman's lifetime; radiation exposure from mammography may slightly ↑breast CA risk. Breast Cancer: Screening. Online Accessed 10/15/19.
11 [ACOG-A] ACOG 2017. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/15/19.
12 ACOG 2021. Committee Opinion No. 823. Health Care for Transgender and Gender Diverse Individuals. March 2021. Online Accessed 6/3/21.
13 [ACS-S] ACS 2015. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update from the American Cancer Society. JAMA. 20 Oct 2015; 314(15)1599-1614. PubMed® abstract | Full-text PDF at PubMed® Central
14 [ACS-Q] ACS 2015. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update from the American Cancer Society. JAMA. 20 Oct 2015; 314(15)1599-1614. PubMed® abstract | Full-text PDF at PubMed® Central
15 [NCCN-1] NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
16 [ACR-9] ACR 2017. ACR Appropriateness Criteria. Breast Cancer Screening. PDF
17 [AAFP-I] AAFP 2016. Insufficient evidence for digital tomosynthesis as primary screening method. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
18 [USPSTF-I] USPSTF 2016. Insufficient evidence for digital tomosynthesis as primary screening method. Breast Cancer: Screening. Online Accessed 10/15/19.
19 ACR 2017. US breast may be appropriate; [ACR-6]; but adjunctive screening MRI, FDG-PEM, Tc-99m sestamibi MBI not recommended d/t insufficient evidence [ACR-3]. ACR Appropriateness Criteria. Breast Cancer Screening. PDF
20 ACOG 2015. Management of Women With Dense Breasts Diagnosed by Mammography. Committee Opinion Number 625, March 2015. Modestly increased breast CA risk, reduced mammography sensitivity seen w/ dense breasts, including BI-RADS 3 and 4, yet current evidence doesn’t show meaningful benefits w/ supplemental/alternative tests (US, MRI, tomosynthesis, thermography) in pts w/o other risk factors. PDF
21 [NCCN-2A] NCCN 2019. Mammographically dense breast tissue assoc w/ increased risk for breast CA and limits mammography sensitivity. Consider pts on risk/benefits of supplemental screening:
• Full-field digital mammography appears to offer benefit in women w/ dense breasts
• Tomosynthesis can ↑detection and ↓call backs, but most studies involved double-dose radiation (2-D reconstruction can ↓doses)
• US. Routine adjunctive use for screening not recommended for dense breasts; may ↑detection rates but also ↑recalls and benign breast bx
• MRI. Insufficient evidence to permit recommending for or against use with mammographically dense breasts
• Molecular imaging (gamma, sestamibi, positron emission). Routine use in dense breasts isn’t supported by current evidence
• Thermography/ductal lavage isn’t supported by current evidence.
NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
22 [USPSTF-I] USPSTF 2016. Breast Cancer: Screening. Online Accessed 10/15/19.
23 NCCN 2019. CBE is considered as part of the clinical “encounter,” along w/ ongoing risk assessment and risk reduction counseling. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
24 ACP 2019. Guidance Statement 4. Qaseem A, et al. Clinical Guidelines. Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians. Ann Intern Med. 2019; M18-2147. Online Accessed 6/25/19.
25 [AAFP-I] AAFP 2016. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
26 NCI 2019. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Clinical breast exam:
• Benefits. Current evidence insufficient to assess additional benefits/harms of CBE. The single RCT comparing high-quality CBE w/ screening mammography showed equivalent benefit. CBE accuracy in community setting might be lower than in the RCT.
• Harms. False(+) w/ additional tests, anxiety. Specificity in women 50-59 yo: 88% to 99%, yielding false(+) rate of 1%-12%. False(-) w/ false reassurance, potential dx delay. Of women w/ CA, 17%-43% have neg CBE. Sensitivity higher w/ longer duration and higher quality exam by trained personnel.
27 [ACOG-C] ACOG 2017. CBE may be offered in context of shared, informed decision-making, recognizing uncertainty of benefits/harms beyond screening mammography. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/15/19.
28 [ACOG-B] ACOG 2017. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/22/19.
29 ACS 2019. American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 10/15/19 .
30 NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
31 [AAFP-D] AAFP 2016. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
32 NCI 2019. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Breast self-exam:
• Benefits. Compared w/ no screening, it hasn’t been shown to reduce breast CA mortality.
• Harms. Based on solid evidence, formal instruction + encouragement to perform BSE leads to more breast bx and dx of more benign breast lesions. Bx rate was 1.8% among study population vs 1.0% among the controls.
33 [ACOG-C] ACOG 2017. Educate on s/sx of breast CA; advise pts to notify clinicians for pain, mass, new-onset nipple discharge, or redness. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/15/19.
34 USPSTF 2016. Breast Cancer: Screening. Online Accessed 10/15/19.
Annual or biennial mammography for average-risk1-3 pts recommended by various groups; guidance varies on tomosynthesis,4-6 breast exam - Biennial mammography screening recommended (ACP,7 AAFP,8 USPSTF9). Discuss evidence, pt preferences, benefits10/harms11,12
- ACOG13 recommends annual or biennial mammography after appropriate counseling; screen transgender men as long as breast tissue present (review op records to ensure mastectomy, not reduction, was performed); screen transgender women biennially once ≥5y on feminizing hormones14
- ACS15 recommends annual mammography for women 45-54 yo; after age 55, transition to biennial screening or offer choice to continue annual mammography; continue screening as long as good health/life expectancy ≥10y
- NCCN16 and ACR17 recommend annual mammography
- Modalities: ACR17 rates tomosynthesis equivalent to mammography; NCCN4 includes tomosynthesis as a consideration. However, AAFP18 and USPSTF19 consider tomosynthesis evidence to be insufficient. US breast may be appropriate (ACR20); however, adjunctive screening MRI, FDG-PEM, Tc-99m sestamibi MBI not recommended/insufficient evidence (ACR20); ACS1 recommends against breast MRI screening for women whose lifetime risk of breast CA is <15%
- If dense breasts: Additional/alternative tests in asymptomatic women w/o additional risk factors not recommended (ACOG21); NCCN22 recommends counseling re: risks vs benefits of supplemental screening; insufficient evidence for US, MRI, breast tomosynthesis (AAFP,23 USPSTF24)
Clinical breast exam (CBE)25 guidance varies: - CBE not recommended due to lack of evidence (ACP,26 ACS15); insufficient evidence to assess benefits/harms (AAFP,27 NCI,28 USPSTF24)
- However, NCCN4 recommends annual CBE (encounter25), as does ACOG29 in context of shared, informed decision-making approach
Breast self-exam (BSE) not recommended: - BSE not recommended d/t lack of evidence (ACOG,30 ACS31) and risk of harm from false-positives (ACOG30)
- NCCN32 cites RCT showing no effect on breast CA mortality
- AAFP33 recommends against teaching BSE; BSE results in more bx and benign lesion dx (NCI34)
Breast self-awareness recommended: - Counsel average-risk women to become familiar w/ normal look/feel of their breasts and report changes to clinicians (NCCN,4 ACOG,35 ACS,31 USPSTF36)
Footnotes 1 ACS 2019.
High risk for breast CA includes:
• Lifetime breast CA risk of ~20%-25% or greater per tools based mainly on FHx (eg, Claus model)
• Known BRCA(+) (based on genetic testing) or untested pt w/ 1st-deg relative BRCA(+)
• RT to chest when 10-30 yo
• Self/1st-deg relative w/ Li-Fraumeni/Cowden/BRR syndromes.
Increased risk for breast CA includes:
• Moderately increased risk: Pts w/ lifetime risk 15%-20% per tools based mainly on FHx
• Increased risk: Personal hx breast CA/DCIS/LCIS/ALH/ADH; dense breasts (extremely or heterogeneously) on mammography.
American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 10/15/19.
2 [NCCN-2A] NCCN 2019. Increased breast CA risk includes:
• Prior hx breast CA
• 5-yr risk of invasive breast CA ≥1.7% in pts ≥35 yo (Gail Model)
• ≥20% lifetime risk (per models mainly dependent on FHx: Claus, BRCAPRO, Tyrer-Cuzick)
• >20% lifetime risk due to LCIS/ALH/ADH
• Thoracic RT btwn ages 10-30 yo
• Pedigree suggestive/known for genetic predisposition.
NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
3 NCI 2019. Howlader N, et al. SEER Cancer Statistics Review, 1975-2016. National Cancer Institute. Updated 9/5/19. Online Accessed 10/22/19.
Risk that a woman will be diagnosed with breast CA during the next 10y, starting at the following ages:
• Age 30: 0.48% (1 in 208)
• Age 40: 1.53% (1 in 65)
• Age 50: 2.38% (1 in 42)
• Age 60: 3.54% (1 in 28)
• Age 70: 4.07% (1 in 25)
Also available: Ethnicity Table.
4 [NCCN-2A] NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
5 [AAFP-I] AAFP 2016. Insufficient evidence for digital tomosynthesis as primary screening method. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
6 [USPSTF-I] USPSTF 2016. Insufficient evidence for digital tomosynthesis as primary screening method. Breast Cancer: Screening. Online Accessed 10/15/19.
7 ACP 2019. Guidance Statement 2. Qaseem A, et al. Clinical Guidelines. Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians. Ann Intern Med. 2019; M18-2147. Online Accessed 6/25/19.
8 [AAFP-B] AAFP 2016. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
9 [USPSTF-B] USPSTF 2016. Breast Cancer: Screening. Online Accessed 10/15/19.
10 NCI 2016. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Mammography benefits:
• Screening mammography reduces breast CA-specific mortality for women 60-69 yo (solid evidence) and for women 50-59 yo (fair evidence) based on RCTs
• Recent pop studies question the benefits of screened populations who participate in screening for longer duration
• Women 30-49 yo: 1,904 women needed to prevent 1 breast CA death
• Women 50-59 yo: 1,339 women needed to prevent 1 breast CA death
• Women 60-69 yo: 377 women needed to prevent 1 breast CA death
• The 25-yr f/u from Canadian National Breast Screening Study (CNBSS) RCT, completed in 2014, showed no mortality benefit assoc w/ mammography screening.
11 NCI 2019. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Mammography harms:
• Over-dx + tx of insignificant cancers that would not have caused sx or death. Certain studies find that btwn 20% and 50% of screen-detected breast CA are over-dx based on pt age, life expectancy, and tumor type (ductal carcinoma in situ and/or invasive).
• False(+) w/ additional tests, anxiety. 10% of women will be recalled from each screening exam for further tests; only 5 of 100 recalled will have CA. Approx 50% of women screened annually for 10y in US will experience a false(+), of whom 7%-17% will have bx. Additional testing less likely when prior mammograms available for comparison.
• False(-) w/ false security, potential dx delay. 6% to 46% of women w/ invasive CA have neg mammogram, esp if young, dense breasts, or mucinous, lobular, or rapidly growing CA.
Radiation-induced breast CA: Radiation-induced mutations can cause breast CA, but w/ radiation doses higher than those used in a single mammography exam. Dose for typical 2-view mammogram is extremely unlikely to cause CA. Theoretically, annual mammogram in women aged 40-80 yrs may cause up to 1 breast CA per 1,000 women.
12 USPSTF 2016. Harms from screening: False-positive results which can lead to psychological harms, additional testing, invasive f/u; over-dx/tx of CA that would never become a threat to a woman’s health or become clinically apparent during a woman's lifetime; radiation exposure from mammography may slightly ↑breast CA risk. Breast Cancer: Screening. Online Accessed 10/15/19.
13 [ACOG-A] ACOG 2017. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/22/19.
14 ACOG 2021. Committee Opinion No. 823. Health Care for Transgender and Gender Diverse Individuals. March 2021. Online Accessed 6/3/21.
15 [ACS-Q] ACS 2015. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update from the American Cancer Society. JAMA. 20 Oct 2015; 314(15)1599-1614. PubMed® abstract | Full-text PDF at PubMed® Central
16 [NCCN-1] NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
17 [ACR-9] ACR 2017. ACR Appropriateness Criteria. Breast Cancer Screening. PDF
18 [AAFP-I] AAFP 2016. Insufficient evidence for digital tomosynthesis as primary screening method. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
19 [USPSTF-I] USPSTF 2016. Insufficient evidence for digital tomosynthesis as primary screening method. Breast Cancer: Screening. Online Accessed 10/15/19.
20 ACR 2017. US breast may be appropriate; [ACR-6]; but adjunctive screening MRI, FDG-PEM, Tc-99m sestamibi MBI not recommended d/t insufficient evidence [ACR-3]. ACR Appropriateness Criteria. Breast Cancer Screening. PDF
21 ACOG 2015. Modestly increased breast CA risk, reduced mammography sensitivity seen w/ dense breasts, including BI-RADS 3 and 4, yet current evidence doesn’t show meaningful benefits w/ supplemental/alternative tests (US, MRI, tomosynthesis, thermography) in pts w/o other risk factors. Management of Women With Dense Breasts Diagnosed by Mammography. Committee Opinion Number 625, March 2015. PDF
22 [NCCN-2A] NCCN 2019. Mammographically dense breast tissue assoc w/ increased risk for breast CA and limits mammography sensitivity. Consider pts on risk/benefits of supplemental screening:
• Full-field digital mammography appears to offer benefit in women w/ dense breasts
• Tomosynthesis can ↑detection and ↓call backs, but most studies involved double-dose radiation (2-D reconstruction can ↓doses)
• US. Routine adjunctive use for screening not recommended for dense breasts; may ↑detection rates but also ↑recalls and benign breast bx
• MRI. Insufficient evidence to permit recommending for or against use with mammographically dense breasts
• Molecular imaging (gamma, sestamibi, positron emission). Routine use in dense breasts isn’t supported by current evidence
• Thermography/ductal lavage isn’t supported by current evidence.
NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
23 [AAFP-I] AAFP 2016. Insufficient evidence for digital tomosynthesis as primary screening method. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
24 [USPSTF-I] USPSTF 2016. Breast Cancer: Screening. Online Accessed 10/15/19.
25 [NCCN-2A] NCCN 2019. CBE is considered as part of the clinical “encounter,” along w/ ongoing risk assessment and risk reduction counseling. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
26 ACP 2019. Guidance Statement 4. Qaseem A, et al. Clinical Guidelines. Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians. Ann Intern Med. 2019; M18-2147. Online Accessed 6/25/19.
27 [AAFP-I] AAFP 2016. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
28 NCI 2019. Breast Cancer Screening–for health professionals. Updated: 9/26/19. Online Accessed 10/22/19.
Clinical breast exam:
• Benefits. Current evidence insufficient to assess additional benefits/harms of CBE. The single RCT comparing high-quality CBE w/ screening mammography showed equivalent benefit. CBE accuracy in community setting might be lower than in the RCT.
• Harms. False(+) w/ additional tests, anxiety. Specificity in women 50-59 yo: 88% to 99%, yielding false(+) rate of 1%-12%. False(-) w/ false reassurance, potential dx delay. Of women w/ CA, 17%-43% have neg CBE. Sensitivity higher w/ longer duration and higher quality exam by trained personnel.
29 [ACOG-C] ACOG 2017. CBE may be offered in context of shared, informed decision-making, recognizing uncertainty of benefits/harms beyond screening mammography. Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/15/19.
30 [ACOG-B] ACOG 2017. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/22/19.
31 ACS 2019. American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 10/15/19.
32 NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
33 [AAFP-D] AAFP 2016. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
34 NCI 2019. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Breast self-exam:
• Benefits. Compared w/ no screening, it hasn’t been shown to reduce breast CA mortality.
• Harms. Based on solid evidence, formal instruction + encouragement to perform BSE leads to more breast bx and dx of more benign breast lesions. Bx rate was 1.8% among study population vs 1.0% among the controls.
35 [ACOG-C] ACOG 2017. Educate on s/sx of breast CA; advise pts to notify clinicians for pain, mass, new-onset nipple discharge, or redness. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/15/19.
36 USPSTF 2016. Breast Cancer: Screening. Online Accessed 10/15/19.
Mammography for average-risk1-3 pts recommended by various groups; guidance varies on tomosynthesis,4 breast exam - ACP4 recommends against screening mammography in average-risk women ≥75 yo w/ life expectancy ≤10y; USPSTF5 and AAFP6 conclude insufficient evidence of benefits/harms for screening mammography
- However, other groups recommend mammography w/o upper age limit: biennially (may offer annually) (ACS7); annually or biennially (ACOG8); annually (NCCN,9 ACR10). Continue screening as long as good health/life expectancy ≥10y (ACS,7 NCCN9); based on shared decision-making and health status (ACOG11)
- ACOG recommends screening transgender men according to existing guidance as long as breast tissue present (review op records to ensure mastectomy, not reduction, was performed); they also recommend screening transgender women biennially once ≥5y on feminizing hormones12
- Modalities: ACR10 rates tomosynthesis equivalent to mammography; NCCN9 includes tomosynthesis as a consideration. US breast may be appropriate (ACR13); however, adjunctive screening MRI, FDG-PEM, Tc-99m sestamibi MBI not recommended/insufficient evidence (ACR13); ACS1 recommends against MRI screening for women whose lifetime risk of breast CA is <15%
- If dense breasts: Additional/alternative tests not recommended in asymptomatic women w/o additional risk factors (ACOG14); NCCN15 recommends counseling re: risks vs benefits of supplemental screening
Clinical breast exam (CBE)16 guidance varies: - CBE not recommended d/t lack of evidence (ACP,17 ACS7); insufficient evidence exists to assess benefits/harms (AAFP,18 NCI19)
- ACOG20 and NCCN9 recommend annual CBE (encounter16)
Breast self-exam (BSE) not recommended: - BSE not recommended d/t lack of evidence (ACOG,21 ACS22) and risk of harm from false-positives (ACOG21)
- AAFP23 recommends against teaching self-exam; self-exam results in more bx and benign lesion dx (NCI24)
Breast self-awareness recommended: - Counsel average-risk women to become familiar w/ normal look/feel of their breasts and report changes to clinicians (NCCN,9 ACOG,25 ACS,22 USPSTF26)
Footnotes 1 ACS 2019.
High risk for breast CA includes:
• Lifetime breast CA risk of ~20%-25% or greater per tools based mainly on FHx (eg, Claus model)
• Known BRCA(+) (based on genetic testing) or untested pt w/ 1st-deg relative BRCA(+)
• RT to chest when 10-30 yo
• Self/1st-deg relative w/ Li-Fraumeni/Cowden/BRR syndromes.
Increased risk for breast CA includes:
• Moderately increased risk: Pts w/ lifetime risk 15%-20% per tools based mainly on FHx
• Increased risk: Personal hx breast CA/DCIS/LCIS/ALH/ADH; dense breasts (extremely or heterogeneously) on mammography.
American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 10/15/19.
2 [NCCN-2A] NCCN 2019. Increased breast CA risk includes:
• Prior hx breast CA
• 5-yr risk of invasive breast CA ≥1.7% in pts ≥35 yo (Gail Model)
• ≥20% lifetime risk (per models mainly dependent on FHx: Claus, BRCAPRO, Tyrer-Cuzick)
• >20% lifetime risk due to LCIS/ALH/ADH
• Thoracic RT btwn ages 10-30 yo
• Pedigree suggestive/known for genetic predisposition.
NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
3 NCI 2019. Howlader N, et al. SEER Cancer Statistics Review, 1975-2016. National Cancer Institute. Updated 9/5/19. Online Accessed 10/22/19. Risk that a woman will be diagnosed with breast CA during the next 10y, starting at the following ages:
• Age 30: 0.48% (1 in 208)
• Age 40: 1.53% (1 in 65)
• Age 50: 2.38% (1 in 42)
• Age 60: 3.54% (1 in 28)
• Age 70: 4.07% (1 in 25)
Also available: Ethnicity Table.
4 ACP 2019. Guidance Statement 3. Qaseem A, et al. Clinical Guidelines. Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians. Ann Intern Med. 2019; M18-2147. Online Accessed 6/25/19.
5 [USPSTF-I] USPSTF 2016. Breast Cancer: Screening. Online Accessed 10/15/19.
6 [AAFP-I] AAFP 2016. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
7 [ACS-Q] ACS 2015. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update from the American Cancer Society. JAMA. 20 Oct 2015; 314(15)1599-1614. PubMed® abstract | Full-text PDF at PubMed® Central
8 [ACOG-A] ACOG 2017. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/22/19.
9 [NCCN-2A] NCCN 2019. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
10 [ACR-9] ACR 2017. ACR Appropriateness Criteria. Breast Cancer Screening. PDF
11 [ACOG-C] ACOG 2017. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/15/19.
12 ACOG 2021. Committee Opinion No. 823. Health Care for Transgender and Gender Diverse Individuals. March 2021. Online Accessed 6/3/21.
13 ACR 2017. US breast may be appropriate [ACR-6]; but adjunctive screening MRI, FDG-PEM, Tc-99m sestamibi MBI not recommended/insufficient evidence [ACR-3]. ACR Appropriateness Criteria. Breast Cancer Screening. PDF
14 ACOG 2015. Management of Women With Dense Breasts Diagnosed by Mammography. Committee Opinion Number 625, March 2015. Modestly increased breast CA risk, reduced mammography sensitivity seen w/ dense breasts, including BI-RADS 3 and 4, yet current evidence doesn’t show meaningful benefits w/ supplemental/alternative tests (US, MRI, tomosynthesis, thermography) in pts w/o other risk factors. PDF
15 [NCCN-2A] NCCN 2017. Mammographically dense breast tissue assoc w/ increased risk for breast CA and limits mammography sensitivity. Consider pts on risk/benefits of supplemental screening:
• Full-field digital mammography appears to offer benefit in women w/ dense breasts
• Tomosynthesis can ↑detection and ↓call backs, but most studies involved double-dose radiation (2-D reconstruction can ↓doses)
• US. Routine adjunctive use for screening not recommended for dense breasts; may ↑detection rates but also ↑recalls and benign breast bx
• MRI. Insufficient evidence to permit recommending for or against use with mammographically dense breasts
• Molecular imaging (gamma, sestamibi, positron emission). Routine use in dense breasts isn’t supported by current evidence
• Thermography/ductal lavage isn’t supported by current evidence.
NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
16 [NCCN-2A] NCCN 2017. CBE is considered as part of the clinical “encounter,” along w/ ongoing risk assessment and risk reduction counseling. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. Version 1.2019. Online Accessed 10/15/19.
17 ACP 2019. Guidance Statement 4. Qaseem A, et al. Clinical Guidelines. Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians. Accessed 6/25/2019; Ann Intern Med. 2019; M18-2147. Online Accessed 6/25/19.
18 AAFP 2016. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
19 NCI 2019. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Clinical breast exam:
• Benefits. Current evidence insufficient to assess additional benefits/harms of CBE. The single RCT comparing high-quality CBE w/ screening mammography showed equivalent benefit. CBE accuracy in community setting might be lower than in the RCT.
• Harms. False(+) w/ additional tests, anxiety. Specificity in women 50-59 yo: 88% to 99%, yielding false(+) rate of 1%-12%. False(-) w/ false reassurance, potential dx delay. Of women w/ CA, 17%-43% have neg CBE. Sensitivity higher w/ longer duration and higher quality exam by trained personnel.
20 [ACOG-C] ACOG 2017. CBE may be offered in context of shared, informed decision-making, recognizing uncertainty of benefits/harms beyond screening mammography. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/15/19.
21 [ACOG-B] ACOG 2017. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/22/19.
22 ACS 2019. American Cancer Society Recommendations for the Early Detection of Breast Cancer. Online Accessed 10/15/19.
23 [AAFP-D] AAFP 2016. Clinical Preventive Service Recommendation. Breast Cancer. Online Accessed 10/17/22.
24 NCI 2019. Breast Cancer Screening–for health professionals. Updated 9/26/19. Online Accessed 10/22/19.
Breast self-exam:
• Benefits. Compared w/ no screening, it hasn’t been shown to reduce breast CA mortality.
• Harms. Based on solid evidence, formal instruction + encouragement to perform BSE leads to more breast bx and dx of more benign breast lesions. Bx rate was 1.8% among study population vs 1.0% among the controls.
25 [ACOG-C] ACOG 2017. Educate on s/sx of breast CA; advise pts to notify clinicians for pain, mass, new-onset nipple discharge, or redness. Practice Bulletin Number 179. Breast Cancer Risk Assessment and Screening in Average Risk Women. July 2017. Online Accessed 10/15/19.
26 USPSTF 2016. Breast Cancer: Screening. Online Accessed 10/15/19.
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