Breast cancer is the most common non-skin cancer and the second deadliest cancer in women. In the US it is estimated that 234,580 women will be diagnosed with invasive breast cancer and 40,030 will die from the disease in 2013. For this reason, breast cancer screening has received more attention and recommendations in order to determine who should be screened and what method to use.

Screening

RISK FACTORS

• Age • Genetics
• Estrogen exposure • Breast density

The Breast Cancer Risk Assessment tool (BCRAT) is a tool used to calculate the breast cancer risk and determine the optimal screening strategy and stratification into risk categories. www.cancer.gov/bcrisktool

IMAGING STUDIES

These imaging studies identify patients that have abnormal or suspicious findings. This is not a cancer diagnosis and still requires further evaluation either by a biopsy of the tissue or follow-up further imaging at a designated interval.

  1. Mammogram is the main screening modality: Digital mammogram is more accurate for pre-menopausal and peri-menopausal women and for dense breasts as compared to traditional film. It detects more cancers on women younger than 50 years but it is also related to more false-positive findings in this group.
  2. Ultrasonography is used as a diagnostic follow-up of an abnormality seen on mammogram.
  3. MRI: Magnetic Resonance Imaging is used in combination with mammograms in high-risk patients. It is recommended by the American Cancer Society (ACS) in women at high risk of breast cancer.
  4. Tomosynthesis: “3D mammography” is a modified digital mammogram. It is approved in combination with conventional mammograms. This technique is promising for women with dense breast tissue and high breast cancer risk, but exposes to more radiation.

WHEN TO DO ROUTINE SCREENING MAMMOGRAPHY

It should be offered to women ages 50 to 69. Consensus is not as strong for women ages 40-49 and over age of 70. There are issues regarding screening due to utilization, especially in those of lower socioeconomic groups and the uninsured. It is suggested to screen with mammograms as long as a woman has a life expectancy of at least 10 years.

FREQUENCY OF MAMMOGRAPHY

Data is limited on the optimal time intervals. Breast cancer on average grows more slowly in older than younger women. Longer intervals may be reasonable on women older than 50 years and annual screening in younger women at higher risk.

BREAST EXAMINATION

  1. Clinical Breast Examination (CBE): is a reasonable cost effective strategy for screening and improves early detection of breast cancer. It is more useful in older women due to increase in fat tissue replacing the glandular one.
  2. Breast Self-Examination: Has not been demonstrated to improve rates of breast cancer diagnosis, or breast cancer death. Studies have shown increased rates of breast biopsy of benign disease among women taught self-breast examination.

FAMILY HISTORY OF BREAST CANCER

For women who have a first-degree relative with history of breast cancer it has been suggested to do screening mammograms at an earlier age especially if the relative had pre-menopausal breast cancer. The ACS recommends a combination of MRI and mammography in women at high risk of breast cancer. Women who test positive for BRCA1 or BRCA2 need more intensive screening strategies. These are inherited germline mutations in the two commonly associated genes, which are at increased risk of both breast and ovarian cancer. These women should receive genetic counseling and get the combination of MRI and mammogram annually.

IN SUMMARY

  • If the lifetime risk of breast cancer is below 15%
  • Ages 40-50: Discuss risks and benefits and determine individual patient risk
  • Ages 50-70: Screen Mammogram
  • Over age 70: Screen Mammogram if their life expectancy is at least 10 years
  • Screen every one to two years
  • Perform clinical breast examination in women getting breast cancer screening, particularly in older women.
  • Self-breast exam should only be performed in conjunction with mammogram and clinical breast exam and not be a substitute for either one.

If the lifetime risk of breast cancer is 20-25% or higher: High Risk Patients

  • Refer for genetic counseling to determine if they have a BRCA mutation and decide management options.
  • If women under this risk strategy chose intensified surveillance: Check annual mammography and breast MRI as well as clinical breast examination every three to six months and monthly self breast exams.
  • It is suggested to begin screening at age 25 for these women.

By Veronica Versari, M.D.

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