Family History Breast Cancer When to Start Mammograms
Breast Cancer Screening Update
Am Fam Physician. 2013 February xv;87(4):274-278.
A more than recent article on breast cancer screening is available.
Related editorial: Screening Mammograpy: The Goal Is Changing.
Article Sections
- Abstract
- Screening Modalities
- Practical Approach to Chest Cancer Screening
- References
Breast cancer is the virtually mutual non–pare cancer and the second leading crusade of cancer decease in North American women. Mammography is the only screening examination shown to reduce breast cancer–related bloodshed. At that place is general understanding that screening should be offered at least biennially to women 50 to 74 years of age. For women twoscore to 49 years of historic period, the risks and benefits of screening should be discussed, and the determination to perform screening should accept into consideration the individual patient adventure, values, and comfort level of the patient and doc. Information is lacking nigh the effectiveness of screening in women 75 years and older. The determination to screen women in this age group should be individualized, keeping the patient's life expectancy, functional status, and goals of intendance in mind. For women with an estimated lifetime breast cancer risk of more than 20 percent or who accept a BRCA mutation, screening should begin at 25 years of age or at the age that is 5 to x years younger than the earliest age that chest cancer was diagnosed in the family. Screening with magnetic resonance imaging may be considered in high-take chances women, simply its impact on breast cancer mortality is uncertain. Clinical breast examination plus mammography seems to be no more effective than mammography alone at reducing breast cancer mortality. Didactics breast cocky-examination does non better mortality and is not recommended; however, women should be aware of any changes in their breasts and written report them promptly.
Breast cancer is the most common non–skin cancer and the second leading cause of cancer death in North American women. In the United States, in that location were an estimated 230,480 new cases of invasive breast cancer and an estimated 39,970 deaths attributed to it in 2011.1 Worldwide, approximately 458,400 deaths were attributed to chest cancer.2
SORT: KEY RECOMMENDATIONS FOR Exercise
| Clinical recommendation | Show rating | References | Comments |
|---|---|---|---|
| Teaching breast self-test does not reduce mortality and is not recommended. | A | 4, 5, 18, 20, 21 | — |
| Clinical breast examination is an pick for women in all risk categories, merely should not replace screening mammography. | C | eight–10, 21 | The U.S. Preventive Services Chore Force states that there is insufficient evidence to back up clinical breast examination.18 |
| Annual or biennial screening mammography should be offered to average-risk women fifty to 74 years of age. | A | 8–x, 18, 20–22 | There is general agreement to screen women 50 to 70 years of age. |
| For average-risk women xl to 49 years of age, the risks and benefits of mammography are closely balanced. The decision to perform screening mammography should take into consideration the private patient risk, values, and comfort level of the patient and physician. | B | 18–21 | Other organizations maintain their strong support to start routine screening at forty years of age.8–10,22 |
| Almanac or biennial screening mammography can be offered to average-hazard women older than 74 years. This decision should be individualized, keeping the patient'due south life expectancy, functional status, and goals of intendance in heed. | C | eight, 10 | — |
In the United states and other industrialized countries, bloodshed rates from chest cancer have been failing by 2.2 percent per year since 1990,2 largely considering of the increased use of screening mammography and greater utilise of adjuvant therapies.3 Although screening mammography has contributed significantly to reducing breast cancer mortality, ongoing controversy remains well-nigh the age at which routine screening should showtime and stop, likewise equally the optimal frequency of screening. This commodity presents current evidence and recommendations for breast cancer screening, and provides a reasonable approach to screening women with mammography based on expected benefits and individual patient risk. The roles of clinical chest examination, breast cocky-exam, magnetic resonance imaging, and other screening tools will likewise be reviewed.
Screening Modalities
- Abstract
- Screening Modalities
- Applied Arroyo to Breast Cancer Screening
- References
BREAST SELF-EXAMINATION
Although it is a common practise, teaching chest self-test does not reduce chest cancer bloodshed and may increase false-positive rates. 2 large randomized trials, ane in China involving more than than 266,000 women and the other in Russia involving more than 120,300 women, did not demonstrate a mortality benefit from pedagogy breast self-examination.4,5 A review of eight other studies did not show a do good for the rate of breast cancer diagnosis, the tumor size or stage, or the rate of death from breast cancer.6
Instead of breast self-examination, some organizations recommend encouraging women 20 years and older to recognize the normal advent and feel of their breasts, without using any systematic examination technique.7–10 The goal of breast cocky-awareness is for women to promptly report any changes in their breasts to their primary care doc.7 Although there are no studies to support this recommendation, the number of times that women find lumps that atomic number 82 to a breast cancer diagnosis warrants educating them to recognize and report changes in their breasts.
CLINICAL Chest Examination
In a written report of 39,405 women 50 to 59 years of age, clinical chest test (CBE) lonely was compared with CBE plus mammography, and later xiii years of follow-up the bloodshed rate was the aforementioned in each group.11,12 A review of controlled trials and case-command studies that included CBE as a screening modality estimated CBE sensitivity and specificity to exist 54 and 94 percent, respectively.13 A subsequent study found that CBE plus mammography had greater sensitivity than mammography lonely, but also had a higher false-positive rate.xiv A literature review performed for the U.S. Preventive Services Job Force (USPSTF) ended that the effectiveness of CBE has not been established in well-designed large trials.fifteen
MAMMOGRAPHY
Screening mammography has been shown to reduce rates of chest cancer mortality. A meta-assay of 13 randomized trials establish a 26 per centum reduction in the relative risk of breast cancer–related bloodshed when women 50 to 74 years of age received screening mammography.16,17
When to Brainstorm Screening. Although in that location is general agreement that screening mammography should be offered routinely to women fifty to 74 years of historic period, there are alien guidelines for its utilize in women 40 to 49 years of age. In 2009, the USPSTF recommended against routine screening mammography in women younger than 50 years, based on the analysis of closely balanced benefits and harms.xviii The USPSTF noted that the rates of false-positive results in young women were nigh double those in women 50 years and older; that the number needed to screen for women 39 to 49 years of age to forbid 1 breast cancer death was much higher than that for women 50 to 59 and lx to 69 years of age (ane,904, one,339, and 377, respectively); and that the risks of overdiagnosis (eastward.m., ductal carcinoma in situ that may not grow or get invasive) and overtreatment were additional potential harms.18
Subsequently the USPSTF recommendations were published, a large Swedish cohort study reported 16-year results comparing breast cancer mortality between women 40 to 49 years of age who were invited to undergo screening (report group) and women in the same historic period group who were non invited (control group).19 Screening every 18 to 24 months was associated with a 26 to 29 pct relative risk reduction in chest cancer bloodshed, with a number needed to screen of 1,252 over 10 years. Even so, this was non a randomized report, and the authors best-selling the possibility of pick bias acquired past differences betwixt the study and control groups.
Although a number of major organizations support the USPSTF recommendations,xx,21 many professional societies and organizations in the United States take maintained their potent support for systematic screening in women older than 40 years.viii–10,22 The USPSTF subsequently updated its recommendation by stating that "the conclusion to start regular, biennial screening mammography earlier the age of l years should be an individual one and have patient context into account, including the patient'south values regarding specific benefits and harms."xviii
When to Stop Screening. The optimal historic period at which to end routine breast cancer screening is uncertain. At that place is no data from clinical trials about the effectiveness of screening mammography in women older than 74 years, and the USPSTF has concluded that the evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years and older.xviii The American Cancer Lodge and the National Comprehensive Cancer Network recommend that as long as an older woman is in good health and remains a candidate for breast cancer treatment if necessary, she should go along to be screened.8,10
Screening Intervals. Most guidelines recommend screening every i to ii years in women fifty years and older. For women xl to 49 years of historic period who desire screening, the American College of Obstetricians and Gynecologists (ACOG) recommends annual mammography.nine ACOG's previous guideline recommended routine mammography every i to 2 years starting at forty years of historic period, and and then annually beginning at 50 years. The comparatively rapid growth of chest cancers in women younger than 50 years and the potential for early detection to reduce mortality in this historic period group were two of the primary reasons cited for the change.9
A contempo modeling study found that a woman's historic period, chest density, family history, and history of breast biopsy bear on the price-effectiveness of screening mammography. Biennial screening for most women l to 74 years of historic period is cost-effective based on a cost per quality-adjusted life-year threshold of $100,000 or less.23
Digital vs. Film Mammography. Studies comparison digital with film mammography have produced conflicting results. However, the Digital Mammographic Imaging Screening Trial, which involved 50,000 asymptomatic women 40 years and older, showed that the overall accuracy of motion-picture show and digital mammography was similar, and that digital mammography is more than sensitive than flick in women younger than l years, in those who are pre-menopausal, and in those with dense breast tissue.24
Limitations of the Prove. Although screening mammography reduces breast cancer mortality, the magnitude of that issue remains uncertain, making it difficult to weigh confronting the potential harms. A Cochrane review acknowledged that screening is likely to reduce breast cancer mortality, but estimated a relative risk reduction of only fifteen percent.25 In improver, the authors likewise noted that screening led to thirty percent overdiagnosis and overtreatment. This means that for every 2,000 women screened over 10 years, ane will accept her life prolonged and 10 healthy women will be treated unnecessarily. Furthermore, more than 200 women will experience prolonged psychological distress related to false-positive findings. Near of the randomized trials of screening mammography were conducted decades ago, when effective treatment options for chest cancer were express, and some studies suggest that improvements in handling may take reduced the magnitude of benefit to be gained from screening.26
ULTRASONOGRAPHY
There are no data that document the value of ultrasound screening lonely. A study comparing mammography solitary with mammography plus ultrasonography in high-risk women with dense breasts institute that the addition of ultrasonography essentially increased the rate of cancer detection, merely at the cost of increased false-positive results (10.4 percentage compared with 4.4 percent for mammography alone).27 The most important use of breast ultrasonography is in the evaluation of suspicious lesions found during screening mammography and of those plant past physical examination only non detected by mammography.
MAGNETIC RESONANCE IMAGING
Magnetic resonance imaging has greater sensitivity than mammography and tin can provide additional information compared with mammography.28,29 Prospective studies, including a large international study, propose that this modality should exist used every bit a screening tool in women at high gamble because of dense breast tissue, family history, or BRCA1 and BRCA2 mutations.xxx–34 However, considering of a lack of standard procedure, operation, and interpretation, the results from one establishment may not be reproducible in another.35 The American Cancer Social club and the National Comprehensive Cancer Network recommend the addition of magnetic resonance imaging to mammography for women with a known BRCA mutation, those with a outset-caste relative who has a BRCA mutation, and those with a lifetime risk of xx percentage or more.8,10 They recommend that screening begin at 25 to 30 years of age, and continue for as long as a woman is in skillful wellness, although the exact timing and screening interval remain unclear.
OTHER SCREENING MODALITIES
Although scintimammography, positron emission tomography, ductal lavage, and thermography have been considered as possible tools for breast cancer screening, none are currently used because of cost, impracticality, or lack of validation in prospective trials.36
Practical Approach to Breast Cancer Screening
- Abstract
- Screening Modalities
- Applied Approach to Chest Cancer Screening
- References
Tabular array 1 summarizes areas of agreement and disagreement amidst various breast cancer screening guidelines.8–10,18,20–22
Table 1.
Summary of Breast Cancer Screening Guidelines
| Screening modality | American Academy of Family Physicians 20 | American Cancer Society ten | American College of Obstetricians and Gynecologists nine | American College of Radiology 22 | Canadian Job Force on Preventive Wellness Intendance 21 | National Comprehensive Cancer Network 8 | U.S. Preventive Services Chore Force 18 |
|---|---|---|---|---|---|---|---|
| Chest cocky-examination | Recommends against | Counsel about benefits and limitations | Breast self-sensation encouraged | — | Recommends against | Chest cocky-awareness encouraged | Recommends against |
| Clinical breast examination | Bereft evidence | Every three years from xx to 39 years of age, and annually thereafter | Every one to three years from 20 to 39 years of age, and annually thereafter | — | Every one to two years start at xl years of historic period | Every one to three years from twenty to 39 years of age, and annually thereafter | Insufficient testify |
| Magnetic resonance imaging | Insufficient evidence | Offer annually to women at high risk | Offer annually to women at high risk | Offer annually to women at high take chances | — | Offer annually to women at loftier risk | Bereft evidence |
| Mammography | Routine biennial screening for women 50 to 74 years of age | Routine annual screening beginning at forty years of historic period | Routine annual screening beginning at forty years of age | Routine almanac screening beginning at xl years of historic period | Routine almanac screening beginning at 50 years of age | Routine annual screening beginning at 40 years of age | Routine biennial screening for women 50 to 74 years of age |
The following approach is recommended based on wide consensus within the guidelines to the care of individual patients:
-
For women 50 to 74 years of age, physicians should offering screening mammography annually or biennially.
-
For women 40 to 49 years of age, risk stratification is an important component of assessing the potential benefits of breast cancer screening. The virtually commonly used risk-prediction model, the Chest Cancer Take a chance Assessment Tool, is available on the National Cancer Constitute Web site (http://www.cancer.gov/bcrisktool/).37 The variables used to calculate five-year and lifetime risk of breast cancer are listed in Table 2.37 For women at loftier risk of chest cancer (i.eastward., a lifetime gamble greater than 20 to 25 percent), or with known BRCA1 or BRCA2 mutations, screening mammography should be recommended. For women at boilerplate risk (lifetime gamble less than 15 pct) or moderate risk (15 to 20 percent), the harms and benefits of mammography should be discussed, and the decision to perform mammography should exist determined past individual patient risk, values, and comfort level. For average-risk women older than 74 years, screening mammography can be considered depending on the patient's health, life expectancy, functional condition, and goals of care.
Table 2.
Factors in the Chest Cancer Risk Assessment Tool
| Historic period |
| Historic period at first menstrual menstruum |
| Age at first alive commitment |
| Number of first-caste relatives (female parent, sisters, daughters) who accept had breast cancer |
| History of breast biopsy |
| Number of breast biopsies (positive or negative) |
| At least one biopsy with singular hyperplasia |
| Race/ethnicity |
Data Sources: A search of electronic databases, including the Cochrane Library, the Agency for Healthcare Enquiry and Quality clinical guidelines and evidence reports, Academic Search Complete, and PubMed, was completed using the fundamental terms chest cancer, breast cancer screening, early detection, mammography, run a risk reduction, and combinations of these terms. The search yielded meta-analyses, randomized controlled trials, clinical trials, and reviews. Search dates were express to January 1, 2000, through Baronial xxx, 2011. Too searched were the Canadian Task Force on Preventive Wellness Care, the National Guideline Clearinghouse, and the U.Southward. Preventive Services Task Force. Lists of key references were also searched in an iterative fashion. Search dates: Baronial 2011 to July 2012.
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