Bottom Line
- Shared decision-making should be used in discussing screening.
- Screening strategies differ based on the estimated risk of breast cancer (starting at age of 40 vs age 50)
Background:
- Breast cancer is the most frequent type of non-skin cancer and second most frequent cause of cancer death in US women.
- Majority of breast cancers in the US are diagnosed as a result of an abnormal screening study.
- Majority of women are at average risk (less than 15 percent lifetime risk) of developing breast cancer.
Guidelines: All North American expert groups recommend mammography for women age 50 and older. There is controversy about screening women in their 40s.
Starting age |
USPSTF, AAFP |
ACS, AMA, NCI, ACOG, NCCN |
Starting age |
50 |
40 |
Interval |
Every 2 years |
Yearly |
Stopping age |
75 |
Until life expectancy is less than 5-7 years |
Risk Factors
- Major risk factors: age, breast density, genetic predisposition (BRCA1/2 ) obesity, family history and estrogen exposure, history of previous radiotherapy to the chest between ages 10 and 30
- If a woman has a family hx of breast, ovarian, adnexal or peritoneal cancer, further family hx should be obtained and genetic testing should be considered.
- Risk prediction tools include the Breast Cancer Risk Assessment Tool (BCRAT)/Gail Model (www.cancer.gov/bcrisktool) or the Breast Cancer Surveillance Consortium (BCSC) model (http://tools.bcsc-scc.org/BC5yearRisk/intro.htm) can be used to consider earlier or more frequent screening.
Other screening modalities
- Breast self-exam
- USPSTF recommends against teaching, as there is no mortality benefit and increases harm.
- ACS recommends women be educated about the benefits and limitations.
- ACOG recommends breast self-awareness, which can include breast self-examination.
- MRI
- More sensitive for cancers in young women, pre-menopausal women, or women with high breast density.
- USPSTF states evidence is insufficient.
- ACS recommends annual MRI (in addition to mammography) for women who:
- Have known BRCA mutations
- Have first-degree relatives with BRCA mutations
- Lifetime risk of >20-25%
- p53 (Li-Fraumen) or PTEN (Cowden syndrome) mutation carriers, or untested 1st degree relatives of a carrier
- Women with hx of chest irradiation at age 10-30