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| {{Breast cancer}} | | {{Breast cancer}} |
| {{CMG}}; {{AE}} [[User:Jack Khouri|Jack Khouri]] | | {{CMG}}; {{AE}} [[User:Jack Khouri|Jack Khouri]], {{MGS}} |
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| ==Overview== | | ==Overview== |
| Breast cancer screening is an attempt to find unsuspected cancers. The most common screening methods include: self and clinical breast exams, x-ray [[mammography]], breast [[magnetic resonance imaging]] (MRI), ultrasound, and genetic testing. | | Breast cancer screening is an attempt to find unsuspected cancers. The most common screening methods include: self and clinical breast exams, x-ray [[mammography]], breast [[magnetic resonance imaging]] (MRI), ultrasound, and genetic testing. |
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| ==X-Ray Mammography== | | ==Screening== |
| [[Image:Mammo breast cancer.jpg|thumb|right|Normal (left) versus cancerous (right) mammography image.]]
| | Three tests are used by health care providers to screen for breast cancer:<ref name = Screening> Breast Cancer. National Cancer Institute (2015) http://www.cancer.gov/types/breast/patient/breast-screening-pdq#section/_13 Accessed on January 15 2016 </ref> |
| Mammography is still the modality of choice for screening of early [[Breast cancer|breast cancer]], since it is relatively fast, reasonably accurate, and widely available in developed countries. Breast cancers detected by mammography are usually much smaller (earlier stage) than those detected by patients or doctors as a breast lump.
| | ===Mammogram=== |
| | | *Mammography is the most common screening test for breast cancer. A mammogram is an x-ray of the breast. This test may find tumors that are too small to feel. Mammograms are less likely to find breast tumors in women younger than 50 years than in older women. This may be because younger women have denser breast tissue that appears white on a mammogram. |
| Due to the high incidence of breast cancer among older women, screening is now recommended in many countries. Recommended screening methods include [[breast self-examination]] and [[mammography]]. Mammography has been estimated to reduce breast cancer-related mortality by 20-30%.<ref>{{cite journal | author = Elwood J, Cox B, Richardson A | title = The effectiveness of breast cancer screening by mammography in younger women. | journal = Online J Curr Clin Trials | volume = Doc No 32 | issue = | pages = [23,227 words; 195 paragraphs] | year = | id = PMID 8305999}}</ref> Routine (annual) mammography of women older than age 40 or 50 is recommended by numerous organizations as a screening method to diagnose early breast cancer; it has demonstrated a protective effect in multiple clinical trials.<ref>{{cite journal | author = Fletcher S, Black W, Harris R, Rimer B, Shapiro S | title = Report of the International Workshop on Screening for Breast Cancer. | journal = J Natl Cancer Inst | volume = 85 | issue = 20 | pages = 1644-56 | year = 1993 | id = PMID 8105098}}</ref> The evidence in favor of mammographic screening comes from eight randomized clinical trials from the 1960s through 1980s. Many of these trials have been criticised for methodological errors, and the results were summarized in a review article published in 1993.<ref name=Fletcher_1993>{{cite journal | author = Fletcher SW, Black W, Harris R, Rimer BK, Shapiro S | title = Report of the International Workshop on Screening for Breast Cancer | journal = J. Natl. Cancer Inst. | volume = 85 | issue = 20 | pages = 1644-56 | year = 1993 | pmid = 8105098 | doi = | accessdate = 2007-05-26}}</ref> A trials with three decade follow-up on breast cancer mortality in Sweden showed that the number of breast cancer screens needed to prevent one death was approximately 414-519.<ref name="pmid21712474">{{cite journal| author=Tabár L, Vitak B, Chen TH, Yen AM, Cohen A, Tot T et al.| title=Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades. | journal=Radiology | year= 2011 | volume= 260 | issue= 3 | pages= 658-63 | pmid=21712474 | doi=10.1148/radiol.11110469 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21712474 }} </ref>
| | *The following may affect whether a mammogram is able to detect (find) breast cancer: |
| | | :*The size of the tumor. |
| Improvements in mortality due to screening are hard to measure; similar difficulty exists in measuring the impact of [[Pap smear]] testing on [[cervical cancer]], although worldwide, the impact of that test is likely enormous. Nationwide mortality due to cancer, before and after the institution of a screening test, is a surrogate indicator about the effectiveness of screening, and the results of mammography are favorable.
| | :*How dense the breast tissue is. |
| | | :*The skill of the radiologist. |
| ===Clinical Practice Guidelines===
| | *Women aged 40 to 74 years who have screening mammograms have a lower chance of dying from breast cancer than women who do not have screening mammograms. |
| There is a discrepancy among breast cancer screening guidelines regarding the age at which screening mammography should begin.
| | ===Clinical breast exam=== |
| * The 2009 [[United States Preventive Services Task Force]] (USPSTF) guidelines for screening for breast cancer recommended screening mammography every two years beginning at the age of 50 ([[United states preventive services task force recommendations scheme|grade B recommendation]]),<ref name="pmid19920272">{{cite journal| author=US Preventive Services Task Force| title=Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. | journal=Ann Intern Med | year= 2009 | volume= 151 | issue= 10 | pages= 716-26, W-236 | pmid=19920272 | doi=10.7326/0003-4819-151-10-200911170-00008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19920272 }} </ref> an age cut-off point that used to be 40 in the 2002 [[USPSTF]] guidelines.<ref name="NCI_MMG_Screening">{{cite web |url=http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional |title=NCI Statement on Mammography Screening - Breast Cancer Screening (PDQ®) |accessdate=2014-09-24 |format= |work=}}</ref><ref name="NCI_MMG_Screening2002">{{cite web |url=http://www.cancer.gov/newscenter/newsfromnci/2002/mammstatement31jan02 |title=NCI Statement on Mammography Screening - National Cancer Institute |accessdate=2014-09-24 |format= |work=}}</ref>
| | *A clinical breast exam is an exam of the breast by a doctor or other health professional. The doctor will carefully feel the breasts and under the arms for lumps or anything else that seems unusual. It is not known if having clinical breast exams decreases the chance of dying from breast cancer. |
| * The 2003 American Cancer Society guidelines for early breast cancer screening recommend that screening mammography begin at the age of 40.<ref name="pmid12809408">{{cite journal| author=Smith RA, Saslow D, Sawyer KA, Burke W, Costanza ME, Evans WP et al.| title=American Cancer Society guidelines for breast cancer screening: update 2003. | journal=CA Cancer J Clin | year= 2003 | volume= 53 | issue= 3 | pages= 141-69 | pmid=12809408 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12809408 }} </ref>
| | *Breast self-exams may be done by women or men to check their breasts for lumps or other changes. It is important to know how your breasts usually look and feel. If you feel any lumps or notice any other changes, talk to your doctor. Doing breast self-exams has not been shown to decrease the chance of dying from breast cancer. |
| * In the UK, women are invited for screening once every three years beginning at age 50. | | ===MRI=== |
| | | *MRI is a procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI). MRI does not use any x-rays. |
| Women with one or more first-degree relatives (mother, sister, daughter) with premenopausal breast cancer should begin screening at an earlier age. It is usually suggested to start screening at an age that is 10 years less than the age at which the relative was diagnosed with breast cancer.
| | *MRI is used as a screening test for women who have one or more of the following: |
| | | :*Certain gene changes, such as in the BRCA1 or BRCA2 genes. |
| ===Criticisms of Screening Mammography===
| | :*A family history (first degree relative, such as a mother, daughter or sister) with breast cancer. |
| Screening mammography risks may outweigh the benefits according to a 2013 systematic review by the [[Cochrane Collaboration]]. Although there is a 15% relative reduction in mortality of breast cancer by screening, [[overdiagnosis]] and non-required treatment is close to 30%, all over 10 years. So over 10 years, with 2000 women, one will avoid death, but 10 will be falsely diagnosed and treated.<ref name="pmid23737396">{{cite journal| author=Gøtzsche PC, Jørgensen KJ| title=Screening for breast cancer with mammography. | journal=Cochrane Database Syst Rev | year= 2013 | volume= 6 | issue= | pages= CD001877 | pmid=23737396 | doi=10.1002/14651858.CD001877.pub5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23737396 }} </ref>
| | :*Certain genetic syndromes, such as Li-Fraumeni or Cowden syndrome. |
| | | *MRIs find breast cancer more often than mammograms do, but it is common for MRI results to appear abnormal even when there isn't any cancer. |
| Prior scientific groups have expressed concern about the public's perceptions of the benefits of breast screening.<ref>{{cite news | first= | last= | coauthors= | title=Women 'misjudge screening benefits' | date= Monday, 15 October, 2001 | publisher= | url =http://news.bbc.co.uk/1/hi/health/1601267.stm | work =BBC | pages = | accessdate = 2007-04-04 | language = }}</ref> In 2001, a controversial review published in [[The Lancet]] claimed that ''there is no reliable evidence that screening for breast cancer reduces mortality''.<ref>{{cite journal |author=Olsen O, Gøtzsche P |title=Cochrane review on screening for breast cancer with mammography |journal=Lancet |volume=358 |issue=9290 |pages=1340-2 |year=2001 |pmid=11684218}}</ref> The results of this study were widely reported in the popular press.<ref>{{cite news | first= | last= | coauthors= | title=New concerns over breast screening | date= Thursday, 18 October, 2001 | publisher= | url =http://news.bbc.co.uk/1/hi/health/1607113.stm | work =BBC | pages = | accessdate = 2007-04-04 | language = }}</ref>
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| False positives are a major problem of mammographic breast cancer screening. Data reported in the UK Million Woman Study indicates that if 134 mammograms are performed, 20 women will be called back for suspicious findings, and four biopsies will be necessary, to diagnose one cancer. Recall rates are higher in the U.S. than in the UK.<ref name="pmid15814020">{{cite journal |author=Smith-Bindman R, Ballard-Barbash R, Miglioretti DL, Patnick J, Kerlikowske K |title=Comparing the performance of mammography screening in the USA and the UK |journal=Journal of medical screening |volume=12 |issue=1 |pages=50-4 |year=2005 |pmid=15814020 |doi=10.1258/0969141053279130}}</ref> The contribution of mammography to the early diagnosis of cancer is controversial, and for those found with benign lesions, mammography can create a high psychological and financial cost.
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| ===Mammography in Women Less than 50 Years Old===
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| Part of the difficulty in interpreting mammograms in younger women stems from the problem of breast density. Radiographically, a dense breast has a preponderance of glandular tissue, and younger age or [[estrogen]] [[hormone replacement therapy]] contribute to mammographic breast density. After menopause, the breast glandular tissue gradually is replaced by fatty tissue, making mammographic interpretation much more accurate. Some authors speculate that part of the contribution of [[estrogen]] [[hormone replacement therapy]] to breast cancer mortality arises from the issue of increased mammographic breast density. Breast density is an independent adverse prognostic factor on breast cancer prognosis.
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| [[Systematic review]]s have concluded:
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| * [[Relative risk]] of mortality due to breast cancer 0.84 ([[Confidence interval|95% CI]]: 0.73 - 0.96) according to the [[Cochrane Collaboration]] in 2013.<ref name="pmid23737396">{{cite journal| author=Gøtzsche PC, Jørgensen KJ| title=Screening for breast cancer with mammography. | journal=Cochrane Database Syst Rev | year= 2013 | volume= 6 | issue= | pages= CD001877 | pmid=23737396 | doi=10.1002/14651858.CD001877.pub5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23737396 }} </ref> | |
| * "Mammography screening reduces breast cancer mortality by 15% for women aged 39 to 49 years ([[relative risk]], 0.85 [95% credible interval, 0.75 to 0.96]; 8 trials) according to the [[United States Preventive Services Task Force)]] in 2009.<ref name="pmid19920273">{{cite journal| author=Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L et al.| title=Screening for breast cancer: an update for the U.S. Preventive Services Task Force. | journal=Ann Intern Med | year= 2009 | volume= 151 | issue= 10 | pages= 727-37, W237-42 | pmid=19920273 | doi=10.7326/0003-4819-151-10-200911170-00009 | pmc=PMC2972726 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19920273 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20157131 Review in: Ann Intern Med. 2010 Feb 16;152(4):JC-27] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20436133 Review in: Evid Based Med. 2010 Apr;15(2):62-3] </ref> | |
| * "Although few women 50 years of age or older have risks from mammography that outweigh the benefits, the evidence suggests that more women 40 to 49 years of age have such risks" according to the [[American College of Physicians]] in 2007.<ref name="pmid17404354">{{cite journal |author=Armstrong K, Moye E, Williams S, Berlin JA, Reynolds EE |title=Screening mammography in women 40 to 49 years of age: a systematic review for the American College of Physicians |journal=Ann. Intern. Med. |volume=146 |issue=7 |pages=516-26 |year=2007 |pmid=17404354 |doi=}}</ref> | |
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| ===Enhancements to Mammography===
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| In general, digital mammography and computer-aided mammography have increased the sensitivity of mammograms, but at the cost of more numerous false positive results.
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| [[Computer-aided diagnosis]](CAD) Systems may help radiologists to evaluate X-ray images to detect breast cancer in an early stage.{{Fact|date=September 2007}} CAD is especially established in US and the Netherlands. It is used in addition to the human evaluation of the diagnostician.
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| ==== Digital Mammography ==== | |
| ===== Overview =====
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| In digital mammography, the processes of image acquisition, display, and storage are separated, which allows optimization of each. Radiation transmitted through the breast is absorbed by an electronic detector, the response of which is faithful over a wide range of intensities. Once this information is recorded, it can be displayed by using computer image-processing techniques to allow arbitrary settings of image brightness and contrast, without the need for further exposure to the patient.<ref name="pmid15670993">Pisano ED, Yaffe MJ (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15670993 Digital mammography.] ''Radiology'' 234 (2):353-62. [http://dx.doi.org/10.1148/radiol.2342030897 DOI:10.1148/radiol.2342030897] PMID: [http://pubmed.gov/15670993 15670993]</ref>
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| Several approaches have been taken in the development of digital mammography systems: (a) slot scanning with a scintillator and a charge-coupled device (CCD) array, (b) a flat-panel scintillator and an amorphous silicon diode array, (c) a flat-panel amorphous selenium array, (d) a tiled scintillator with fiberoptic tapers and a CCD array, and (e) photostimulable phosphor plates (computed radiography).<ref name="pmid15537982">{{cite journal |author=Mahesh M |title=AAPM/RSNA physics tutorial for residents: digital mammography: an overview |journal=[[Radiographics : a Review Publication of the Radiological Society of North America, Inc]] |volume=24 |issue=6 |pages=1747–60 |year=2004 |pmid=15537982 |doi=10.1148/rg.246045102 |url=http://radiographics.rsnajnls.org/cgi/pmidlookup?view=long&pmid=15537982 |accessdate=2011-12-02}}</ref>
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| ===== Advantages =====
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| *Better contrast resolution for dense breasts
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| *reduction in recall rates
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| *potential for reduction in radiation dose
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| *increased patient throughput, post-processing capability, and digital acquisition<ref name="pmid15537982">{{cite journal |author=Mahesh M |title=AAPM/RSNA physics tutorial for residents: digital mammography: an overview |journal=[[Radiographics : a Review Publication of the Radiological Society of North America, Inc]] |volume=24 |issue=6 |pages=1747–60 |year=2004 |pmid=15537982 |doi=10.1148/rg.246045102 |url=http://radiographics.rsnajnls.org/cgi/pmidlookup?view=long&pmid=15537982 |accessdate=2011-12-02}}</ref>
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| As mentioned above, a film mammography's sensitivity for detecting breast cancer in women with radiographically dense breast tissue is limited. A study, which was published in the New England Journal of Medicine, aimed at assessing the role of digital mammography in screening for breast cancer in women with dense breasts. The study concluded that the overall diagnostic accuracy of digital and film mammography as a means of screening for breast cancer is similar, but digital mammography is more accurate in women under the age of 50 years, women with radiographically dense breasts, and premenopausal or perimenopausal women.<ref name="pmid16169887">Pisano ED, Gatsonis C, Hendrick E, Yaffe M, Baum JK, Acharyya S et al. (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16169887 Diagnostic performance of digital versus film mammography for breast-cancer screening.] ''N Engl J Med'' 353 (17):1773-83. [http://dx.doi.org/10.1056/NEJMoa052911 DOI:10.1056/NEJMoa052911] PMID: [http://pubmed.gov/16169887 16169887]</ref>
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| ==Breast MRI==
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| [[Magnetic resonance imaging]] (MRI) has been shown to detect cancers not visible on mammograms, but has long been regarded to have disadvantages. For example, although it is 27-36% more sensitive, it is less specific than mammography.<ref>{{cite journal | author = Hrung J, Sonnad S, Schwartz J, Langlotz C | title = Accuracy of MR imaging in the work-up of suspicious breast lesions: a diagnostic meta-analysis. | journal = Acad Radiol | volume = 6 | issue = 7 | pages = 387-97 | year = 1999 | id = PMID 10410164}}</ref> As a result, MRI studies will have more [[Type I and type II errors|false positives]] (up to 5%), which may have undesirable financial and psychological costs. It is also a relatively expensive procedure, and one which requires the intravenous injection of a chemical agent to be effective.
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| Proposed indications for using MRI for screening include:<ref>{{cite journal | author = Morrow M | title = Magnetic resonance imaging in breast cancer: one step forward, two steps back? | journal = JAMA | volume = 292 | issue = 22 | pages = 2779-80 | year = 2004 | id = PMID 15585740}}</ref>
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| *Strong family history of breast cancer
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| *Patients with BRCA-1 or BRCA-2 oncogene mutations
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| *Evaluation of women with breast implants
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| *History of previous lumpectomy or breast biopsy surgeries
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| *Axillary metastasis with an unknown primary tumor
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| *Very dense or scarred breast tissue
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| However, two studies published in 2007 demonstrated the strengths of [[MRI]]-based screening:
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| *In March 2007, an article published in the ''[[New England Journal of Medicine]]'' demonstrated that in 3.1% of patients with breast cancer, whose [[contralateral]] breast was clinically and mammographically tumor-free, [[MRI]] could detect breast cancer. [[Sensitivity (tests)|Sensitivity]] for detection of breast cancer in this study was 91%, [[Specificity (tests)|specificity]] 88%.<ref>{{cite journal | author = Lehman CD, Gatsonis C, Kuhl CK, Hendrick RE, Pisano ED, Hanna L, Peacock S, Smazal SF, Maki DD, Julian TB, DePeri ER, Bluemke DA, Schnall MD | title = MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer.| journal = N Engl J Med.| volume = 356 | issue = 13| pages = 1295-1303| year = 2007 | id = PMID 17392300}}</ref>
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| *In August 2007, an article published in ''[[The Lancet]]'' compared [[MRI]] breast cancer screening to conventional mammographic screening in 7,319 women. [[MRI]] screening was highly more sensitive (97% in the MRI group vs. 56% in the mammography group) in recognizing early high-grade [[Carcinoma in situ| Ductal Carcinoma in situ (DCIS)]], the most important precursor of invasive carcinoma. Despite the high [[Sensitivity (tests)|sensitivity]], MRI screening had a [[positive predictive value]] of 52%, which is totally accepted for cancer screening tests.<ref>{{cite journal | author = Kuhl CK, Schrading S, Bieling HB, Wardelmann E, Leutner CC, Koenig R, Kuhn W, Schild HH| title = MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study| journal = The Lancet | volume = 370 | issue = 9586 | pages = 485-492 | year = 2007 | id = PMID }}</ref> The author of a comment published in the same issue of ''The Lancet'' concludes that "MRI outperforms mammography in tumour detection and diagnosis."<ref>{{cite journal | author = Boetes C, Mann RM| title = Ductal carcinoma in situ and breast MRI| journal = The Lancet | volume = 370 | issue = 9586 | pages = 459-460 | year = 2007 | id = PMID }}</ref> | |
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| === The American Cancer Society Guidelines for Breast Cancer Screening with MRI as an Adjunct to Mammography ===
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| According to the American Cancer Society guidelines, screening MRI is recommended for:<ref name="pmid17392385">{{cite journal |author=Saslow D, Boetes C, Burke W, Harms S, Leach MO, Lehman CD, Morris E, Pisano E, Schnall M, Sener S, Smith RA, Warner E, Yaffe M, Andrews KS, Russell CA |title=American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography |journal=[[CA: a Cancer Journal for Clinicians]] |volume=57 |issue=2 |pages=75–89 |year=2007 |pmid=17392385 |doi= |url= |accessdate=2011-12-05}}</ref>
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| *Women with a strong family history of breast and ovarian cancer | |
| *Carriers of the BRCA mutation
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| *Women with a history of chest radiation between the ages of 10 and 30 years for Hodgkin disease
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| *Women with a lifetime risk greater than 20% to 25% as defined by risk predication models dependent on family history
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| There are several risk subgroups for which the available data are insufficient to recommend for or against screening, including women with a personal history of breast cancer, carcinoma in situ, atypical hyperplasia, and extremely dense breasts on mammography.
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| ==Breast Ultrasound==
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| [[Medical ultrasonography|Ultrasound]] alone is not usually employed as a screening tool but it is a useful additional tool for the characterization of palpable tumours and directing image-guided biopsies. U-Systems is a US-based company that is selling a breast-cancer detection system using ultrasound that is fully-automated. Using an ultrasound allows a look at dense breast tissue which is not possible with digital mammmography. It is closely correlated with the digital mammography. The other significant advantage over digital mammography is that it is a pain-free procedure.
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| ==Breast Self-Exam==
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| [[Breast self-examination]] was widely discussed in the 1990s as a useful modality for detecting breast cancer at an earlier stage of presentation. A large clinical trial in China reduced enthusiasm for breast self-exam. In the trial, reported in the ''Journal of the National Cancer Institute'' first in 1997 and updated in 2002, 132,979 female Chinese factory workers were taught by nurses at their factories to perform monthly breast self-exam, while 133,085 other workers were not taught self-exam. The women taught self-exam tended to detect more breast nodules, but their breast cancer mortality rate was no different from that of women in the control group. In other words, women taught breast self-exam were mostly likely to detect benign breast disease, but were just as likely to die of breast cancer.<ref name="pmid12359854">{{cite journal |author=Thomas DB, Gao DL, Ray RM, ''et al'' |title=Randomized trial of breast self-examination in Shanghai: final results |journal=J. Natl. Cancer Inst. |volume=94 |issue=19 |pages=1445-57 |year=2002 |pmid=12359854 |doi=}}</ref> An editorial in the Journal of the National Cancer Institute reported in 2002, "Routinely Teaching Breast Self-Examination is Dead. What Does This Mean?"<ref name="pmid12359843">{{cite journal |author=Harris R, Kinsinger LS |title=Routinely teaching breast self-examination is dead. What does this mean? |journal=J. Natl. Cancer Inst. |volume=94 |issue=19 |pages=1420-1 |year=2002 |pmid=12359843 |doi=}}</ref>
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| ==BRCA Testing==
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| ====Approach to Genetic Testing====
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| {{Family tree/start}}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|A1|A1=<div style="float: left; text-align: left; height: 5em; width: 45em; padding:1em;"> '''Assess women with:'''
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| ----
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| ❑ No previous diagnosis with BRCA related cancer, and <br> ❑ Absence of signs and symptoms of any BRCA related cancer</div>}}
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| ----
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|B1|B1=<div style="float: left; text-align: left; height: 15em; width: 45em; padding:1em;">'''Risk assessment: is ANY of the following history factors present?'''<br>
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| ----
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| ❑ Family members with breast, ovarian, tubal or peritoneal cancer<br>
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| ❑ Breast cancer diagnosis before age of 50 years<br>
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| ❑ History of bilateral breast cancer<br>
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| ❑ Presence of both breast and ovarian cancer<br>
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| ❑ Breast cancer in one or more male family members<br>
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| ❑ Multiple breast cancer cases in the family<br>
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| ❑ One or more family members with two primary types of BRCA related cancers<br>
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| ❑ Ashkenazi Jewish ethnicity
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| </div>}}
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|C2| C2=<div style="float: left; text-align: left; height: 2em; width: 45em; padding:1em;"> '''Yes?'''</div>}}
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|C1|C1=<div style="float: left; text-align: left; height: 10em; width: 45em; padding:1em;">'''Screening with ANY of the following:'''
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| ----
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| ❑ [[Risk stratification tools for BRCA related cancers#Ontario Family History Assessment Tool|Ontario Family History Assessment Tool]]<br>
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| ❑ [[BRCA screening tools#Manchester Scoring System|Manchester Scoring System]]<br>
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| ❑ [[BRCA screening tools#Referral Screening Tool|Referral Screening Tool]]<br>
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| ❑ [[BRCA screening tools#Pedigree Assessment Tool|Pedigree Assessment Tool]]<br>
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| ❑ [[BRCA screening tools#FHS-7|FHS-7]]<br>
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| </div>}}
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|C2| C2=<div style="float: left; text-align: left; height: 2em; width: 45em; padding:1em;"> '''High risk of potentially harmful BRCA mutation based on screening?'''</div>}}
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|D1|D1=<div style="float: left; text-align: left; height: 10em; width: 45em; padding:1em;">'''Genetic counseling'''
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| ----
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| ❑ Risk assessment for presence of potential BRCA mutation <br>❑ Educating patients about the possible genetic testing results <br>❑ Risk assessment of family members to identify suitable candidates for genetic testing<br>❑ Discussion about risk reducing interventions <br>❑ Post-test counseling </div>}}
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|E1|E1=<div style="float: left; text-align: left; height: 2em; width: 45em; padding:1em;">'''BRCA mutation genetic testing'''</div>}}
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| {{Family tree/end}}
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| Algorithm based on the 2013 [[US Preventive Services Task Force]] recommendation statement.<ref name="pmid24366376">{{cite journal| author=Moyer VA| title=Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: U.S. Preventive Services Task Force Recommendation Statement. | journal=Ann Intern Med | year= 2013 | volume= | issue= | pages= | pmid=24366376 | doi=10.7326/M13-2747 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24366376 }} </ref>
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| ==Screening Guidelines==
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| {|Class="wikitable"
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| |-
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| |'''Organisation'''||'''Year of the Issued Guidelines''' || '''Mammography''' ||'''Clinical Breast Examination''' || '''Breast Self-Examination''' || '''Imaging'''
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| |- style="height:75px"
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| |USPSTF||2009 ||Age 50-74 years: every 2 years <br> Age 40-49 or >75: individualize decision <br> (every 2 years if performed)||Insufficient evidence for recommendation || Not recommended || Insufficient evidence for recommendation
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| |- style="height:75px"
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| |American Cancer Society ||2010||Age >40 years: annually||Age 20-39 years: every 3 years<br>age >40 years: annually ||Optional ||MRI annually in high risk women<br> (20% lifetime risk of breast cancer,<br> positive BRCA mutations, <br> history of radiation therapy)
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| |- style="height:75px"
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| |American College of Obstetricians and Gynecologists ||2011||Age >40 years: annually ||Age 20-39 years: every 3 years <br> >40 years: annually ||Encouraged ||Not recommended
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| |}
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| ==Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: U.S. Preventive Services Task Force Recommendation Statement (DO NOT EDIT)<ref name="pmid24366376">{{cite journal| author=Moyer VA| title=Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: U.S. Preventive Services Task Force Recommendation Statement. | journal=Ann Intern Med | year= 2013 | volume= | issue= | pages= | pmid=24366376 | doi=10.7326/M13-2747 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24366376 }} </ref>==
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| ===Clinical Summary of U.S. Preventive Services Task Force Recommendation===
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| {|class="wikitable"
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Screen women whose family history may be associated with an increased risk for potentially harmful BRCA mutations. Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. ''([[USPSTF guidelines classification scheme#Evidence Quality Rating|Grade B]])''<nowiki>"</nowiki>
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| |}
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| {|class="wikitable"
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| | bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Do not routinely recommend genetic counseling or BRCA testing to women whose family history is not associated with an increased risk for potentially harmful BRCA mutations. ''([[USPSTF guidelines classification scheme#Evidence Quality Rating|Grade D]])''<nowiki>"</nowiki>
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| |-
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| |}
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| ==References== | | ==References== |
