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Guidelines

Guidelines Summary

Multiple guidelines are available pertaining to breast cancer screening. The three most cited include those by the American College of Physicians (2015), the American Cancer Society (2015), and the United States Preventive Services Task Force (2016).

American College of Physicians (ACP) screening guidelines recommend the following^[96]:

Mammography every 2 years from age 50-74 years
For women aged 40-49 years, guidelines advocate an individualized approach in which clinicians should base decisions on the potential benefits and harms of mammography, the woman's preferences, and her breast cancer risk profile
Current evidence recommends against breast cancer screening with mammography in women younger than 40 years, women older than 75 years, and women with a serious medical condition who have a life expectancy of less than 10 years. However, physicians and patients should discuss the risks and benefits of mammography based on the patient’s wishes and other associated breast cancer risks.

American Cancer Society (ACS) screening guidelines recommend the following^[97]:

For women aged 40-44 years, the choice to begin annual breast cancer screening with mammography should be based on the potential risks/benefits and patient’s wishes.
For women aged 45-54 years, mammography should be completed annually.
For women aged 55 years and older, mammography should be completed every 2 years and continued until life expectancy falls below 10 years.

The US Preventive Services Task Force (USPSTF) screening guidelines recommend the following^[98]:

Mammography every 2 years between age 50 and 74 years
For women aged 40-49 years, guidelines advocate an individualized approach in which clinicians should base decisions on the potential benefits and harms of mammography, the woman's preferences, and her breast cancer risk profile
The USPSTF has found insufficient evidence to make a recommendation about breast cancer screening in women younger than 40 years or older than 75 years.

The above guidelines share the following recommendations:

No clear recommendations for breast self-examination
No clear recommendation for clinical breast examination

ACP and ACS guidelines do not recommend the use of MRI or digital breast tomosynthesis for the purposes of breast cancer screening. USPSTF has found insufficient evidence to provide a recommendation about either of these breast cancer screening modalities.

French College of Gynecologists and Obstetricians (CNGOF) screening guidelines recommend the following^[99]:

Screening with breast ultrasonography in combination with mammography is needed to investigate a clinical breast mass (grade B), colored single-pore breast nipple discharge (grade C), or mastitis (grade C).
The BI-RADS system is recommended for describing and classifying abnormal breast imaging findings.
For a breast abscess, a percutaneous biopsy is recommended in the case of a mass or persistent symptoms (grade C).
For mastalgia, when breast imaging findings are normal, no MRI or breast biopsy is recommended (grade C). Percutaneous biopsy is recommended for a BI-RADS category 4-5 mass (grade B).
For persistent erythematous nipple or atypical eczema lesions, a nipple biopsy is recommended (grade C).
For distortion and asymmetry, a vacuum core-needle biopsy is recommended owing to the risk of underestimation by simple core-needle biopsy (grade C).
For BI-RADS category 4-5 microcalcifications without any ultrasound signal, a minimum 11-G vacuum core-needle biopsy is recommended (grade B). In the absence of microcalcifications on radiography cores, additional samples are recommended (grade B).
For atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ, flat epithelial atypia, radial scar and mucocele with atypia, surgical excision is commonly recommended (grade C). Expectant management is feasible after multidisciplinary consensus. For these lesions, when excision margins are not clear, no new excision is recommended except for LCIS characterized as pleomorphic or with necrosis (grade C).
For grade 1 phyllodes tumor, surgical resection with clear margins is recommended.
For grade 2 phyllodes tumor, 10-mm margins are recommended (grade C).
For papillary breast lesions without atypia, complete disappearance of the radiological signal is recommended (grade C).
For papillary breast lesions with atypia, complete surgical excision is recommended (grade C).

Medication

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Media Gallery

Ultrasonogram demonstrates a hypoechoic mass with smooth, partially lobulated margins typical of a fibroadenoma.
Craniocaudal mammograms obtained 1 year apart demonstrate a newly developing mass in the outer part of the breast.
Spot compression mammogram of the outer part of the breast demonstrates a new mass as smooth, margined, and oval. The findings are consistent with a fibroadenoma, a cyst, or a malignancy. In this patient, the diagnosis was a rapidly growing fibroadenoma.
Eggshell or rim calcifications (arrows) have walls thinner than those of lucent-centered calcifications.
This mass with associated large, coarse calcifications (arrows) is a degenerating fibroadenoma.
Breast cancer, ultrasonography. Mediolateral oblique digital mammogram of the right breast in a 66-year-old woman with a new, opaque, irregular mass approximately 1 cm in diameter. The mass has spiculated margins in the middle third of the right breast at the 10-o'clock position. Image demonstrates both the spiculated mass (black arrow) and separate anterior focal asymmetry (white arrow).
Breast cancer, ultrasonography. Antiradial sonogram of the spiculated mass (shown in the image above) demonstrates a hypoechoic mass with angular margins (black arrows). Cursors on the margins of the mass were used to electronically measure its dimensions of the mass, which was 0.9 X 0.8 cm.
Breast cyst. A) A simple, fairly round breast cyst with hypo or anechoic contents and well-defined borders; B) Posterior acoustic enhancement is seen as well as edge shadows (arrows).
Breast adenoma. A) A breast adenoma is oval with well-defined borders. It may be hypoechoic and some internal echogenicity may be seen. It is wider than tall and posterior acoustic enhancement is NOT seen, helping distinguish from a cyst or other fluid collection. B) An arrow indicates the adenoma.
Breast hematoma. A) A breast hematoma is seen as a round echogenic collection with surrounding tissue edema. A hematoma may be hypoechoic, mixed, or fairly echogenic depending on the stage of the hematoma. B) The hematoma is outlined and tissue edema noted.
Loculated breast abscess. A) A large loculated abscess is seen containing hypoechoic fluid and some internal echoes. Posterior acoustic enhancement is seen. Care must be taken to image at an adequate depth to visualize posterior borders of breast lesions. B) The abscess is outlined in yellow and the posterior acoustic enhancement is noted.
Loculated breast abscess, curvilinear. A) This is the same abscess seen in the above image and is imaged with a curvilinear transducer to better appreciate the extent of the abscess. It is important to image the abscess completely for width and depth. B) The abscess is outlined in yellow and the ribs and posterior acoustic enhancement are noted.
Purulent breast abscess. A) A purulent breast abscess is seen. The fluid is echogenic, but can be recognized as a disruption of the surrounding tissue and posterior acoustic enhancement. B) The abscess is outlined in yellow and the posterior acoustic enhancement is noted.
Complex breast abscess. In this clip, the features of a loculated breast abscess containing echogenic purulent material are noted. Example of imaging with a linear high-frequency transducer.
Loculated breast abscess, curvilinear. In this clip, a large, loculated breast abscess and its features are noted. Example of imaging with a lower-frequency curvilinear transducer to better appreciate the extent of this large abscess.

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Author

Andrew C Miller, MD, FACEP, FAIM, Dip ABIM Chief, Department of Emergency Medicine, Alton Memorial Hospital, BJC HealthCare; Facility Medical Director, TEAMHealth (West Group)

Andrew C Miller, MD, FACEP, FAIM, Dip ABIM is a member of the following medical societies: American College of Academic International Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Phanniram B Sumanam, MD Resident Physician, Department of Emergency Medicine, Nazareth Hospital; Hospitalist, Fox Chase Cancer Center, Abington Hospital-Jefferson Health, and Nazareth Hospital

Phanniram B Sumanam, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Barry J Sheridan, DO Chief Warrior in Transition Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician / Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Prisma Health Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor - Chief Editor for Medscape.

Additional Contributors

Caitlin Kennedy, MD Resident Physician, Department of Emergency Medicine, West Virginia University School of Medicine

Caitlin Kennedy, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John W Hall, IV West Virginia University School of Medicine

John W Hall, IV is a member of the following medical societies: American Medical Association, American Medical Student Association/Foundation, Phi Beta Kappa

Disclosure: Nothing to disclose.

Suha Abdulkarim Khafaji, MBBS Research Physician, Department of Emergency Medicine, West Virginia University School of Medicine

Disclosure: Nothing to disclose.

Joseph J Minardi, MD Associate Professor, Department of Emergency Medicine, Department of Medical Education, West Virginia University School of Medicine; Director of Emergency Ultrasound, Department of Emergency Medicine, West Virginia University Hospitals

Joseph J Minardi, MD is a member of the following medical societies: Academy of Emergency Ultrasound, American College of Emergency Physicians, American Institute of Ultrasound in Medicine, American Medical Association, American Registry for Diagnostic Medical Sonography, American Society of Echocardiography, Emergency Ultrasound Fellowship, Society for Academic Emergency Medicine, Society of Ultrasound in Medical Education

Disclosure: Nothing to disclose.

Alexandra R King, PharmD, DABAT Clinical Pharmacist, Emergency Medicine and Toxicology, Vidant Medical Center

Alexandra R King, PharmD, DABAT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Clinical Pharmacy, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Celia Escamilla, MD Resident Physician, Department of Emergency Medicine, Vidant Medical Center, The Brody School of Medicine at East Carolina University

Disclosure: Nothing to disclose.

Dalal H Alsaggabi, MD Postdoctoral Research Scientist/Fellow, Langone Medical Center, New York University School of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Sadia Hussain, MD, Tajinderpal Saraon, MD, Mark Silverberg, MD, Howard A Blumstein, MD, and Amy K Rontal, MD, to the development and writing of this article.

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