Breast cancer screening

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2]Jack Khouri, Mirdula Sharma, MBBS [3]

Overview

According to the the U.S. Preventive Service Task Force (USPSTF), screening for breast cancer by mammogram is recommended for women aged 50-74 years, twice a year.

Screening

Three tests are used by health care providers to screen for breast cancer:

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.
• The following may affect whether a mammogram is able to detect (find) breast cancer:

• Size of the tumor
• How dense the is breast tissue?
• The radiologist knowledge and expertness

• 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.

Clinical breast exam

• 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.
• Doing breast self-exams has not been shown to decrease the chance of dying from breast cancer.
• The USPSTF recommends against teaching breast self-examination (BSE). There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

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.
• 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.
• A family history (first degree relative, such as a mother, daughter or sister) with breast cancer.
• 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. (False positive)

The New Recommendations

• Women should begin yearly mammogram by the age of 45 years.
• At age 55 years, women should have mammogram every other year should continue as long as the women is in good health.
• Breast exams are no longer recommended.
• Because of variation in life style, genes as well as the other risk factors of breast cancer, national studies in each country is warranted in order to precisely determine the cut of point for age of starting screening.

U.S. Preventive Service Task Force (USPSTF) sreening for breast cancer

Breast cancer screening: summary of recommendations
Population	Recommendation	Grade (please refer to the next table below)
Women, Age 50-74 Years	The USPSTF recommends biennial screening mammography for women 50-74 years.	B
Women, Before the Age of 50 Years	The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.	C
Women, 75 Years and Older	The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of screening mammography in women 75 years and older. Go to the Clinical Considerations section for information on risk assessment and suggestions for practice regarding the I statement.	I
All Women	The USPSTF recommends against teaching breast self-examination (BSE).	D
Women, 40 Years and Older	The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Go to the Clinical Considerations section for information on risk assessment and suggestions for practice regarding the I statement.	I
All Women	The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. Go to the Clinical Considerations section for information on risk assessment and suggestions for practice regarding the I statement.	I

	Grade definitions after July 2012
Grade	Definition	Suggestions for Practice
A	The USPSTF recommends the service. There is high certainty that the net benefit is substantial.	Offer or provide this service.
B	The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.	Offer or provide this service.
C	The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.	Offer or provide this service for selected patients depending on individual circumstances.
D	The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.	Discourage the use of this service.
I	The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.	Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

Level of certainty
Level of Certainty*	Description
High	The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.
Moderate	The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as: The number, size, or quality of individual studies. Inconsistency of findings across individual studies. Limited generalizability of findings to routine primary care practice. Lack of coherence in the chain of evidence.As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.
Low	The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of: The limited number or size of studies. Important flaws in study design or methods. Inconsistency of findings across individual studies. Gaps in the chain of evidence. Findings not generalizable to routine primary care practice. Lack of information on important health outcomes.More information may allow estimation of effects on health outcomes.

References

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