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What are the recommendations for breast cancer screening?

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Key concept

The average lifetime risk of breast cancer for a woman in the United States is estimated to be 12.3%. The mortality rate from breast cancer has decreased 38% from 1989 through 2014. This decrease has been partly attributed to mammographic screening.

The components of a breast screening evaluation depend on age and on medical and family history. These can include breast awareness (patient familiarity with her breasts), clinical encounters (eg, breast cancer risk assessment and clinical breast exam), breast imaging with screening mammography, and, in selected cases, breast MRI.

Patients are stratified into average or high risk groups (those with >20% lifetime risk) based on history and risk prediction tools.

Clinical scenario

A 31-year-old woman presents to establish her care with a primary care physician. She is worried about her risk of breast cancer due to her mother having had breast cancer at age 38 and her maternal aunt at age 42. She wants to know if she should do increased screening for breast cancer.

Action items

Major factors used to determine a risk category, based on a patient’s history, are:

  • Personal history of ovarian, peritoneal (including tubal), or breast cancer

  • Family history of breast, ovarian, or peritoneal cancer with lifetime risk of >20% as defined by models based on that history

  • Genetic predisposition (if the patient’s BRCA or other genetic marker status is known)

  • Radiotherapy to the chest between ages 10 and 30 years

  • 5-year risk of invasive breast cancer >1.7% in women ≥35 years old, or

    • ≥20% lifetime risk if personal history of lobular carcinoma in situ or breast abnormalities such as atypical ductal hyperplasia and atypical lobular hyperplasia

Patients with any of the above factors are considered to be at increased lifetime risk for breast cancer.

Patients with a family pedigree suggestive of a known genetic predisposition should be referred for genetic counseling and testing. If testing is negative, prediction models can be used to estimate lifetime risk and guide screening recommendations and start age.

Discussion

Average-risk screening recommendations per NCCN guidelines:

  • Age 25–40: clinical encounter every 1–3 years and breast awareness

  • Age >40: annual clinical encounter and screening mammogram with consideration of tomosynthesis and breast awareness

Increased-risk screening recommendations:

  • Depending on patient-specific risk factors, start age recommendations vary

  • For family history–related risk, screening mammogram recommended to start 10 years younger than the youngest relative diagnosed with breast cancer (but not before age 30) and screening may include:

    • More frequent clinical encounters every 6–12 months

    • Consideration of yearly MRI in addition to screening mammogram (this can start as young as age 25, depending on the risk factor)

    • Breast awareness

  • Some patients with increased risk are candidates for risk reduction strategies (including risk-reducing agents and surgery)

Pearls
  • Only patients at very high risk, such as those with BRCA mutations, are considered for risk-reducing mastectomies and/or risk-reducing bilateral salpingoophorectomy

References
  1. Siegel ...

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