Guidelines Summary
American College of Obstetricians and Gynecologists screening guidelines
The ACOG recommendations include the following. [53]
Recommendations based on good and consistent scientific evidence (level A)
Women at average risk of breast cancer should be offered screening mammography starting at age 40 years. Women at average risk of breast cancer should initiate screening mammography no earlier than age 40 years. If they have not initiated screening in their 40s, they should begin screening mammography by no later than age 50 years. The decision about the age to begin mammography screening should be made through a shared decision-making process. This discussion should include information about the potential benefits and harms.
Women at average risk of breast cancer should have screening mammography every 1 or 2 years based on an informed, shared decision-making process that includes a discussion of the benefits and harms of annual and biennial screening and incorporates patient values and preferences. Biennial screening mammography, particularly after age 55 years, is a reasonable option to reduce the frequency of harms, as long as patient counseling includes a discussion that with decreased screening comes some reduction in benefits.
Women at average risk of breast cancer should continue screening mammography until at least age 75 years.
Recommendations based on limited or inconsistent scientific evidence (level B)
Health care providers periodically should assess breast cancer risk by reviewing the patient’s history.
Women with a potentially increased risk of breast cancer based on initial history should have further risk assessment.
Breast self-examination is not recommended in average-risk women because there is a risk of harm from false-positive test results and a lack of evidence of benefit.
Recommendations based primarily on consensus and expert opinion (level C)
Screening clinical breast examination may be offered to asymptomatic, average-risk women in the context of an informed, shared decision-making approach that recognizes the uncertainty of additional benefits and the possibility of adverse consequences of clinical breast examination beyond screening mammography. If performed for screening, intervals of every 1-3 years for women aged 25-39 years and annually for women aged 40 years and older are reasonable. The clinical breast examination continues to be a recommended part of evaluation of high-risk women and women with symptoms.
Average-risk women should be counseled about breast self-awareness and encouraged to notify their health care provider if they experience a change. Breast self-awareness is defined as a woman’s awareness of the normal appearance and feel of her breasts.
Age alone should not be the basis to continue or discontinue screening. Beyond age 75 years, the decision to discontinue screening mammography should be based on a shared decision making process informed by the woman’s health status and longevity.
American Cancer Society screening guidelines
The ACS recommendations include the following [54] :
-
Women should begin regular screening mammography at age 45 years (strong recommendation)
-
Women aged 45-54 years should be screened annually (qualified recommendation)
-
Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually (qualified recommendation)
-
Women should have the opportunity to begin annual screening at 40-44 years of age (qualified recommendation)
-
Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (qualified recommendation)
-
Clinical breast examination is not recommended for breast cancer screening in average-risk women at any age
U.S. Preventive Services Task Force screening guidelines
The USPSTF breast examination recommendations include the following [55, 56] :
-
No requirement for clinicians to teach women how to perform BSE (Grade D recommendation)
-
Insufficient current evidence to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older
The USPSTF screening mammography recommendations are as follows:
-
No requirement for routine screening mammography in women aged 40 to 49 years (Grade C recommendation); the decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient's values regarding specific benefits and harms
-
Biennial screening mammography for women between the ages of 50 and 74 years (Grade B recommendation)
-
Insufficient current evidence to assess the additional benefits and harms of screening mammography in women 75 years or older
-
Insufficient current evidence to assess the additional benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer
-
Insufficient current evidence to assess the additional benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram
European Commission Initiative on Breast Cancer screening guidelines
The ECIBC screening guidelines include the following recommendations for women age 40-74 years who are at average risk of breast cancer [57] :
-
Age 40-44: no screening
-
Age 45-49: screening every 2 or 3 years
-
Age 50-69: screening every 2 years
-
Age 70-74: screening every 3 years
In addition, for asymptomatic women with an average risk for breast cancer, screening with digital mammography is recommended over DBT for breast cancer screening. The guidelines also suggest that screening with digital mammography alone is preferred over screening with both DBT and digital mammography.
For women with dense breast tissue and negative mammography findings, ECIBC suggests not implementing tailored screening with automated breast ultrasound system (ABUS), hand-held ultrasound (HHUS), or MRI.
National Comprehensive Cancer Network screening guidelines
The NCCN on screening in average-risk women includes the following recommendations [42] :
-
Clinical breast examinations every 1-years from age 25-39, then annually from age 40 on
-
Begin annual screening mammography at age 40 years.
-
Consider tomosynthesis (three-dimensional mammography)
NCCN guidelines provide 4 separate sets of recommendations for women at increased risk, on the basis of personal or family history, These include earlier initiation of mammography, in some cases, and consideration or recommendation of annual MRI. Additional considerations include the following:
-
An upper age limit for screening is not yet established. Consider severe comorbid conditions limiting life expectancy (eg, ≤10 years) and whether therapeutic interventions are planned.
-
For women with heterogeneous dense breasts and dense breast tissue, recommend counseling on the risks and benefits of supplemental screening.
-
Dense breasts limit the sensitivity of mammography and are associated with an increased risk for breast cancer.
-
Full-field digital mammography appears to benefit young women and women with dense breasts.
-
Multiple studies show that tomosynthesis can decrease callback rates and appears to improve cancer detection. Most studies used double the dose of radiation, but the radiation dose can be minimized by using synthesized 2-D reconstruction.
-
Hand-held or automated ultrasound can increase cancer detection, but may increase recall and benign breast biopsies.
-
Current evidence does not support the routine use of molecular imaging (eg, breast-specific gamma imaging, sestamibi scan, or positron emission mammography) as screening procedures, but emerging evidence suggests that these tests may improve detection of early breast cancers in women with mammographically dense breasts. However, the whole-body effective radiation dose with these tests is between 20 –30 times higher than that of mammography.
-
Current evidence does not support the routine use of thermography or ductal lavage as screening procedures.
-
Trends in female breast cancer death rates by race and ethnicity, US, 1975-2010. Since the widespread adoption of screening mammography in the later 80s, the death rate from breast cancer has decreased 34%. Courtesy of the American Cancer Society (American Cancer Society. Breast Cancer Facts and Figures 2013-2014. Atlanta: American Cancer Society, Inc.).
-
Normal four-view mammogram showing breasts that are extremely dense (BI-RADS category D).
-
Normal four-view mammogram showing breasts that are almost entirely fatty (BI-RADS category A) with very little parenchyma.
-
Screening mammogram depicts malignant pleomorphic microcalcifications in a linear branching distribution.
-
A four-view mammogram shows a highly suspicious mass with spiculated margins and increased density in the right lower outer quadrant: an invasive ductal carcinoma.
-
Image from a mammogram shows a benign mass: a fibroadenoma with well-defined edges and a halo sign.
-
Benign microcalcifications: secretory change.
-
Bilateral mammogram shows diffuse inflammatory carcinoma of the left breast, which appears smaller and more dense than the right breast.
-
Traumatic fat necrosis. Mammogram shows traumatic fat necrosis following removal of a lesion. The stellate lesion has a halo center.
-
Standard 2D mammogram (left) is normal. The corresponding slice from the tomosynthesis (right) taken at the same time shows a mass with architectural distortion.
-
Mammographic spot image during a ductogram shows contrast (white) within the catheter and branching ductal system.
-
An ultrasound of a benign breast mass with circumscribed margins and oval shape; in this case, the mass is a fibroadenoma.
-
Ultrasound shows a suspicious hypoechoic mass with angular margins; in this case, the mass is an invasive ductal carcinoma.
-
Ultrasound shows an anechoic cyst with smooth margins and enhanced through transmission. This is benign and does not need any imaging follow-up.
-
T1-weighted image with fat suppression before contrast. There is a large cyst in the right breast. The cancer in the left breast is isointense to normal tissue and very difficult to see.
-
Same patient as in previous image: T1-weighted image with fat suppression after contrast clearly shows the posterior cancer invading the pectoralis major on the left.
-
Anatomy of the breast.
Tables
Category |
Description |
Risk of Malignancy |
Care Plan and Comments |
1 |
Negative |
5 in 10,000 |
Continue annual screening mammography for women 40 years of age or older. |
2 |
Benign finding, noncancerous |
5 in 10,000 |
Continue annual screening mammography for women 40 years of age or older. This category is for cases with a characteristically benign finding (eg, cyst, fibroadenoma). |
3 |
Probably benign finding |
< 2% |
Usually, 6-month follow-up mammography is performed. Most category 3 abnormalities are not evaluated with biopsy. |
4 |
Suspicious abnormality |
25-50% |
Most category 4 abnormalities are benign but may require biopsy. |
5 |
Highly suggestive of malignancy |
75-99%, depending on how individual radiologists define categories 4 and 5 |
Classic signs of cancer are seen on the mammogram. All category 5 abnormalities are typically evaluated with biopsy; if the results are benign, repeat biopsy is done to ensure correct sampling. |
