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screening for breast cancer

Indications: 1) mammography a) biennial mammography for all women age 40-74 (USPSTF) [71] - formerly women age 50-74 [10,37,38,42] (USPSTF, ACP) - for women age 40-49, choice was based on patient preferences & family history [37,38] (shared decision making) (USPSTF, ACP) - for most women age 40-49, potential harms outweighed the benefits [62] - new USPSTF, ACP recommendations (age 40-74 years) will avert 1.3 additional breast cancer-related deaths with lifetime biennial screening of 1000 women [71] - cost of new recommendations is 60% increase in false positives with associated complications of unnecessary workup [71] - annually after age 40 endorsed by National Comprehensive Cancer Network (NCCN) (controversial recommendation) [69] - screening women 70-74 years may lower 8-year breast cancer mortality by 1 death per 1000 women [65] - screening in women >= 75 years of no benefit [65] - insufficient evidence (USPSTF) [71] - annual screening for women with very dense breast tissue [47,67] - for average risk women with fatty breasts, triennial screening is cost-effective [7]; biennial screening is not [47] - shared decision making [59] b) American Cancer Society recommends annual screening mammography for all women age 45-54 & biennial screening for women age >=55 until life expectancy is < 10 years [40,51] - women should have the opportunity to begin annual screening mammography at age 40 & continue annual screening indefinitely [40] - clinical breast examination for average-risk women of any age not recommended [40] c) American Congress of Obstetrics & Gynecology (ACOG) 1] women should be offered screening mammography beginning at age 40 [52] 2] if women don't start screening in their 40s, they should do so at age 50 3] the decision on when to begin screening should follow a discussion of the potential benefits & harms of screening 4] formerly annual mammography beginning at age 40 [15] 5] screening should occur every 1 or 2 years, depending on the patient's preference [2] 6] women should be screened until at least age 75 - after this, the decision whether to stop screening should follow a discussion of the woman's current health & life expectancy 7] clinical breast exam can be offered to women aged 25-39 every 1 to 3 years 8] for women >= 40 years, clinical breast exam can be offered annually [52] d) screening older women every 2 years reduces false positives (29% vs 48% for annual screening) without change in characteristics of breast cancer diagnoses [22] e) no mortality advantage with annual screening mammography - overdiagnosis in > 20% of lesions found [28] - screening mammography leads to more overdiagnosis than early detection [48] - mortality reduction with annual screening mammography [53] a] annual screening at ages 40-84 > annual screening at ages 45-54, then biennial screening until age 79 > biennial screening at ages 50 (12 vs 9 vs 7 per 1000 women screened) b] same screening stategies would lead to 481,000, 286,000, & 163,000 benign biopsies for some 2.5 million women [53] c] editorialist notes analysis focuses on benefits of screening without adequately considering harms [53] - little effect on reducing rates of advanced breast cancer or mortality from breast cancer in the Netherlands [55] f) no consensus on upper age limit to discontinue screening, but USPSTF & ACP suggests upper age limit of 75 [10,42, 62] - screening should discontinued in women with life expectancy < 10 years [8,51,62] g) gain in life expectancy by screening older women not clear - clinical trials have not included women > 74 years of age, thus benefits of screening for breast cancer with mammography in patients >= 75 years of age is unknown [27] - breast cancer detection rate 1.72 per 1000 for women age 40-44 years & 6.58 per 1000 for women age >= 90 [51] h) continued routine screening after age 69 years may lead to overdiagnosis [33] i) screening mammography reduces mortality [4] - 414 women screened for 7 years to save 1 life [16] o) evidence may not support screening [1] k) results in overdiagnosis of 30-50% [7] - overdiagnosis increases most substantially at older ages l) does not reduce rate of mastectomy [17] m) increased risk of breast cancer with false-positive mammography [18] (seems too much potential for financial gain to exclude marketing bias) n) AI-supported mammography screening results in a similar rate of cancer detection reading by 2 radiologist, with a substantially lower radiologist workload [70] 2) dense breast tissue a) women with heterogenously dense or extremely dense breast tissue (BI-RADS categories) should undergo routine digital screening mammography [8,46] b) ultrasonography as an adjunctive screening test to mammography for women with dense breast tissue results in overdiagnosis [39,61] c) clinical & computer assessments of breast density with similar ability to predict risk of breast cancer [58] 3) special considerations for high risk women* 4) insufficient evidence to recommend for or against digital tomosynthesis (3-D digital mammography) or adjunctive screening methods in women with dense breasts with negative mammogram [42] 5) annual magnetic resonance imaging (MRI) + mammography for high-risk women - lifetime risk of breast cancer of > 20-25% - begin screening 5-10 years earlier than youngest age family member diagnosed with breast cancer or presumptively age 30-35 years which ever comes first - MRI may be more sensitive than mammogram [2,3,11]# - MRI associated with higher rates of subsequent biopsy, but lower yield of breast cancer findings [57] - unlike mammography, breast MRI detects tumor neovascularity & perineoplastic inflammation [32] - MRI not recommended for screening in average-risk women [8] - rapid MRI protocol may become cost-effective [32] - yield of breast cancer via MRI = 1.6% [64] - most small ductal carcinoma in situ - interval breast cancers within 2 years of biennial mammogram lower lower with breast MRI than in mammography alone (2.5 vs 5.0 per 1000) [64] - ACS recommendations for screening with MRI [8] - women with BRCA gene mutation - 1st degree relative of BRCA gene mutation carrier - women with a strong family history of breast cancer & >= 20% lifetime risk of breast cancer - history of chest radiation between age 10 & 30 years (mantle radiation for Hodgkin's disease) - annual MRI to begin at age 25 or 8 years after radiation therapy [8] - history of familial breast cancer syndrome [8] - MRI added to digital breast tomosynthesis based on breast density, would result in 7.4 breast cancer deaths prevented & 884 false-positive recalls per 1000 women during lifetime screening [72] 6) a breast lump should be biopsied, even after a normal mammogram [8] (see breast lump) 7) USPSTF recommends primary care screening for women at risk for BRCA gene mutation with brief familial risk assessment tool [63] 8) BRCA1/BRCA2 genotyping in women with a family history of breast cancer or ovarian cancer [24] - age 25-30 years: - clinical breast examination every 6-12 months - breast imaging annually (optimally, MRI with contrast) [54] - age >= 30 years: - annual mammography & MRI, alternating every 6 months [54] Contraindications: 1) monthly self breast exam beginning at age 20 a) USPSTF recommends against teaching women to perform self breast exams b) data insufficient to recommend self-examination [8] 2) professional breast exam of questionable benefit a) every 3 years ages 20-39 b) professional breast exam (added to mammography) yields 55 additional false-positives for every 1 additional case of breast cancer detected [9] c) do not use clinical breast exams as screening tool [62] Epidemiology: 1) screening differences may account for much of higher risk* of breast cancer with poor prognosis in black women relative to white women [5] 2) mortality reduction from breast cancer due to screening is 2.4 per 100,000 or ~ 1/3 of the 7.2 deaths from breast cancer [12] 3) screening mammography associated with widespread overdiagnosis without reduction in mortality [39] 4) according to GRS9 [27] screening for breast cancer reduces the incidence of breast cancer 5) interval breast cancer detected between screeninga associated with higher mortality than breast cancer detected during routine screening mammography [66] * special considerations for high-risk women - assess genetic predisposition by obtaining a 3-generation family history of breast cancer, ovarian cancer & other cancers [8] - only women with a positive family history should receive genetic testing [8] - women having received chest irradiation between age 10-30 (see # below) - also see risk factors for breast cancer & management of high-risk women # Annual mammography & MRI screening for high-risk: [2,7,8,25] - begin screening 5-10 years earlier than youngest age family member diagnosed with breast cancer or presumptively age 30-35 years which ever comes first - women with BRCA1 &/or BRCA2 mutations - 1st degree relatives of BRCA carriers - women with 20% or greater lifetime risk, assessed by - BRCAPRO & other family-history-dependent models - women having received chest irradiation between age 10-30 - annual mammography [8] - women with Li-Fraumeni syndrome, Cowden syndrome, & Bannayan-Riley-Ruvalcaba syndrome or their 1st degree relatives Insufficient evidence to recommend for or against MRI screening for: - women with a lifetime risk of 15-20% - women with lobular carcinoma in situ or atypical lobular hyperplasia - women with atypical ductal hyperplasia - women with heterogeneous or extreme breast density on mammography - women with a personal history of breast cancer, including ductal carcinoma in situ MRI not recommended for women with a less than 15% lifetime risk Notes: 1) 81% of women comply with USPSTF recommendations for screening, yet 34% of breast cancers present at late stage [13] 2) 81% of physicians recommend screening mammography beginning at age 40 (USPSTF & American Cancer Society do not recommend this, only American Congress of Obstetrics & Gynecology & National Comprehensive Cancer Network (NCCN) do [50,108] 2) breast cancer presenting between screening more likely to have poor prognosis [14] 3) 71% of women who die of breast cancer were not regularly screened [26] 4) false positive screening results discourage subsequent screenings [73] 5) overdiagnosis of invasive breast cancer due to mammography screening [19] - 1/3 of breast cancers may be a result of overdiagnosis [20]; > 20% [28] - ductal carcinoma in situ, although not a life-threatening condition, is treated similarly to invasive breast cancer [35] - screening is not associated with a decrease in advanced tumors [49] - 1 in 3 invasive tumors & ductal carcinoma in situ cases diagnosed after screening were overdiagnoses [49] - 15% of breast cancer screening diagnoses are overdiagnoses [68] 6) mortality reduction due to screening a) 2.4 per 100,000 or ~1/3 (2.4/7.2) of the 7.2 per 100,000 deaths from breast cancer [12] b) no mortality reduction with annual mammography [28] c) overall breast cancer mortality has declined similarly (40-42%) in women > 40 & women < 40 years of age [20] - women < 40 years of age are not frequently screened [20] d) biennial screening mammography is associated with a statistically significant reduction in breast cancer mortality [31] - an editorialist comments: this modest mortality reduction needs to be weighed against harms including overdiagnosis, emotional stress, & high costs associated with widespread screening [31] 7) prognosis of women with interval breast cancers (detected between mammograms) is the same as that of women with breast cancers diagnosed without mammography screening [21] 8) screening 1000 women for 10 years prevents 1 breast cancer related death [23] 9) 50% of women who die of breast cancer are <50 years of age [26] 10) higher frequency of detection of ductal carcinoma in situ associated with lower frequency of prevention of breast cancer [41] 11) 12-20% of elderly women screened for breast cancer despite failing eligibilty requirements [43] 12) out-of-pocket costs reduce screening rates in women age 65-74 [56]

Related

breast cancer mammography risk factors for breast cancer & management of high-risk women

General

screening for cancer

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