Breast Cancer Screening

Aka: Breast Cancer Screening, Screening for Breast Cancer

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II. Efficacy: Breast Cancer Screening

  1. Overall
    1. Screening (especially Mammogram) contributed to 23% less mortality 1990-2000
    2. Berry (2005) N Engl J Med 353(17): 1784-92 [PubMed]
  2. Breast Self Exam
    1. Test Sensitivity: 12-41% of detected cancers
    2. Category D recommendation (not found as effective screening tool and may cause harm)
    3. See Self Breast Exam for details including efficacy
    4. Self Breast Exam is no longer routinely recommended due to low efficacy (see above)
      1. Does not lead to decreased Breast Cancer mortality
      2. High risk of False Positives
    5. Consider a Breast self-awareness protocol as an alternative
      1. Women 20 years and older recognize normal appearance and feel of their Breasts (without systematic self-exam)
      2. Women who find new Breast changes should seek prompt medical attention
      3. McCready (2005) J Clin Nurs 14(5): 570-8 [PubMed]
  3. Clinical Breast Exam
    1. Test Sensitivity: 40-69% of detected cancers
    2. Test Specificity: 88-99%
  4. Mammogram
    1. Test Sensitivity: 77-95% of detected cancers
    2. Test Specificity: 94-97%
      1. Women under age 50 years have False PositiveMammogram rate nearly double women over age 50 years
    3. Number Needed to Screen to prevent a single Breast Cancer death
      1. Ages 39 to 49 years: 1904
      2. Ages 50 to 59 years: 1339
      3. Ages 60 to 69 years: 377
  5. Breast MRI
    1. High Risk Women
      1. Test Sensitivity: 71-100% (Mammogram 16-40% in the same studies)
      2. Test Specificity: 81-99% (Mammogram 93-99% in the same studies)
      3. Saslow (2007) CA Cancer J Clin 57(2): 75-89 [PubMed]
  6. Breast Ultrasound
    1. Dense Breast Tissue
      1. When used as adjunct to Mammogram does increase Test Sensitivity
      2. However, Test Specificity decreases with an increase in False Positive Rate
      3. Berg (2012) JAMA 307(13): 1394-1404 [PubMed]
      4. Lee (2019) JAMA Intern Med 179(5): 658-67 [PubMed]

III. Guidelines: Available Screening Modalities

  1. Standard modalities
    1. Breast Self Exam (BSE) or Breast Self Awareness (see above)
    2. Clinical Breast Examination (CBE)
    3. Mammogram
  2. High risk patients
    1. Breast Cancer Gene Marker (BRCA1 or BRCA2)
    2. Breast MRI
  3. Experimental
    1. Breast Specific Gamma Imaging (BSGI)
      1. New cardiolite-based modality
      2. Significantly improves on efficacy compared with old scintimammography
      3. Indicated in hyperdense Breasts or moderate risk patients not meeting criteria for Breast MRI
    2. Rechtman (2014) AJR Am J Roentgenol 202(2):293-8 [PubMed]

IV. Risk Factors: Breast Cancer Risk Assessment Tool

  1. See Breast Cancer Risk Factors
  2. Calculates 5 year and lifetime risk
  3. Based on most significant Breast Cancer Risk Factors
    1. Age, Menarche and age at first delivery
    2. Race and ethnicity
    3. First degree relatives with Breast Cancer
    4. Number of Breast biopsies and whether any had atypical hyperplasia
  4. Gail Model Breast Cancer Risk Calculator (BCRAT)
    1. https://bcrisktool.cancer.gov//
  5. Breast Cancer Surveillance Consortium Model
    1. https://tools.bcsc-scc.org/BC5yearRisk/calculator.htm

V. Guidelines: Low or Average Risk Screening

  1. Ages 20-39 years
    1. Clinical Breast Examination (CBE) every 1-3 years (optional)
      1. Offer every 1 to 3 years between ages 25-39 years (per ACOG, NCCN)
      2. Not recommended by USPTF (low efficacy, high False Positive Rate)
    2. Monthly Breast Self Exam (BSE) is no longer routinely recommended
      1. Consider a Breast self-awareness protocol as an alternative (see above)
  2. Age 40-49 years
    1. Clinical Breast Examination (CBE) every year (optional)
      1. Offer annual Breast Exam (per ACOG, NCCN)
    2. Monthly Breast Self Exam (BSE) is no longer routinely recommended
      1. Consider a Breast self-awareness protocol as an alternative (see above)
    3. Mammogram every 1-2 years (controversial)
      1. USPTF since 2009 has left screening age 40-50 up to provider and patient and in light of individual risk factors
        1. High mammogram False Positive Rate in women ages 40-50 years
        2. Number Needed to Screen to prevent one Breast Cancer death is much higher in younger women (see above)
      2. ACOG recommends annual to biennial Mammography for women aged 40-50 years old
        1. Lower Incidence of advanced cancer at diagnosis (younger women have more aggressive tumors)
        2. White (2004) J Natl Cancer Inst 96:1832-9 [PubMed]
      3. ACS recommends annual screening for ages 45 to 54 years, then biennial screening (every other year)
  3. Age 50 and over
    1. Clinical Breast Examination (CBE) every year
    2. Mammogram annually
      1. USPSTF Strength of Recommendation: A
      2. ACS recommends annual Mammogram age 45 to 54 years,then biennial screening (every other year)
    3. Monthly Breast Self Exam (BSE) is no longer routinely recommended
      1. Consider a Breast self-awareness protocol as an alternative (see above)
  4. Age 65 and over
    1. Clinical Breast Examination (CBE) every year
    2. Mammogram every 2 years
      1. Consider less frequent if reduced Life Expectancy
    3. Monthly Breast Self Exam (BSE) is no longer routinely recommended
      1. Consider a Breast self-awareness protocol as an alternative (see above)
    4. References
      1. Mandelblatt (2003) Ann Intern Med 139:835-42 [PubMed]
  5. Age to stop screening
    1. No guideline offers specific age, although many stop screening at age 75 years and older
    2. Reasonable to continue screening in otherwise healthy, elderly women over age 75 years
      1. ACS and NCCN recommend screening if Life Expectancy >10 years
      2. ACR and American Geriatric Association recommend screening if Life Expectancy >5-7 years

VI. Guidelines: High Risk by Risk Assessment Tool (Lifetime Risk: 20-85%)

  1. See Breast Cancer Gene Marker Testing Indications
  2. Criteria (See Risk Assessment tools above)
    1. Breast Cancer Gene Marker (BRCA1 or BRCA2) Carrier
    2. Known Breast Cancer Syndrome
    3. Very Strong Family History
      1. Two or more affected first degree relatives
        1. Breast Cancer
        2. Ovarian Cancer
      2. One first degree relative under age 40 years
      3. Affected premenopausal first degree relative
  3. Screening Guidelines
    1. Clinical Breast Exam
      1. Every 6-12 months after age 25 years (ACOG)
    2. Mammogram
      1. Annually after age 30 years (ACOG)
    3. Breast MRI with contrast
      1. Annually starting at age 25 years (ACOG) to 30 years (ACS)

VII. Guidelines: Adjusted for Past Medical History

  1. Atypical Hyperplasia
    1. Negative Family History (Lifetime Risk: 15-20%)
      1. Annual Clinical Breast Exam
      2. Annual Mammogram
    2. Positive Family History (Lifetime Risk over 20%)
      1. Clinical Breast Exam every 6 months
      2. Annual Mammogram: after age 40 or after diagnosis
      3. Breast MRI: Starting at age 30 years (consider)
  2. Lobular Carcinoma in situ (Lifetime Risk 20-30%)
    1. Clinical Breast Exam every 6 months
    2. Annual Mammogram after diagnosis
    3. Breast MRI: Consider starting at age 30 years

VIII. References

  1. (1997) ACOG Opinion, no. 185
  2. Khan (2020) Am Fam Physician 103(1): 33-41 [PubMed]
  3. Knutson (2007) Am Fam Physician 75:1600-6 [PubMed]
  4. Leitch (1997) CA Cancer J Clin 47:150-3 [PubMed]
  5. Smith (2000) CA Cancer J Clin 50:34-49 [PubMed]
  6. Tirona (2013) Am Fam Physician 87(4): 274-8 [PubMed]
  7. Woloshin (2010) JAMA 303(2): 160-1 [PubMed]
  8. Zoorob (2001) Am Fam Physician 63(6):1101-12 [PubMed]

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