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Breast Cancer Screening Guidelines 2020

Who Is Breast Screening For

BREAST CANCER SCREENING in 2020: mammography, ultrasound, MRI — what you need to know

BreastScreen Australia is the national breast screening program and actively invites women aged 5074 to have a free two yearly mammogram. Women aged 4049 and those aged over 74 are also eligible to receive a free mammogram but do not receive an invitation.

It is important to continue to attend screening when you are invited to do so.

Harms Of Mammographic Screening

The negative effects of screening mammography are overdiagnosis , false positives , false negatives , discomfort associated with the test, radiation risk, psychological harm, financial stress, and opportunity costs.

Table 1 provides an overview of the estimated benefits and harms of screening mammography for 10,000 women who underwent annual screening mammography over a 10-year period.

Table 1. Estimated Benefits and Harms of Mammography Screening for 10,000 Women Who Underwent Annual Screening Mammography During a 10-Year Perioda

Age, y

Malmo, Sweden 1976

Östergötland , Sweden 1977

Kopparberg , Sweden 1977

Edinburgh, United Kingdom 1976

The study design and conduct make these results difficult to assess or combinewith the results of other trials.

National Breast Screening Study -1, Canada 1980

NBSS-2, Canada 1980

  • External audit: Yes. Independent with analysis of data by several reviewers.
  • Follow-up duration: 25 years.
  • Relative risk of breast cancer death, screening versus control: 1.02
  • This trial is unique in that it compares one screening modality toanother and does not include an unscreened control. Regarding criticisms andcomments about this trial, see NBSS-1.

Stockholm, Sweden 1981

Gothenburg, Sweden 1982

AGE Trial

Colon And Rectal Cancer And Polyps

For people at average risk for colorectal cancer, the American Cancer Society recommends starting regular screening at age 45. This can be done either with a sensitive test that looks for signs of cancer in a persons stool , or with an exam that looks at the colon and rectum . Talk to your health care provider about which tests might be good options for you, and to your insurance provider about your coverage. No matter which test you choose, the most important thing is to get screened.

If youre in good health, you should continue regular screening through age 75.

For people ages 76 through 85, talk with your health care provider about whether continuing to get screened is right for you. When deciding, take into account your own preferences, overall health, and past screening history.

People over 85 should no longer get colorectal cancer screening.

If you choose to be screened with a test other than colonoscopy, any abnormal test result needs to be followed up with a colonoscopy.

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Benefit And Harms Of Screening And Early Treatment

The USPSTF found adequate evidence that mammography screening reduces breast cancer mortality in women aged 40 to 74 years. The number of breast cancer deaths averted increases with age women aged 40 to 49 years benefit the least and women aged 60 to 69 years benefit the most. Age is the most important risk factor for breast cancer, and the increased benefit observed with age is at least partly due to the increase in risk. Women aged 40 to 49 years who have a first-degree relative with breast cancer have a risk for breast cancer similar to that of women aged 50 to 59 years without a family history. Direct evidence about the benefits of screening mammography in women aged 75 years or older is lacking.

The USPSTF found adequate evidence that screening for breast cancer with mammography results in harms for women aged 40 to 74 years. The most important harm is the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to a womans health, or even apparent, during her lifetime . False-positive results are common and lead to unnecessary and sometimes invasive follow-up testing, with the potential for psychological harms . False-negative results also occur and may provide false reassurance. Radiation-induced breast cancer and resulting death can also occur, although the number of both of these events is predicted to be low.

Clinical Considerations And Recommendations

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How should individual breast cancer risk be assessed?

Health care providers periodically should assess breast cancer risk by reviewing the patients history. Breast cancer risk assessment is based on a combination of the various factors that can affect risk Box 1610111213. Initial assessment should elicit information about reproductive risk factors, results of prior biopsies, ionizing radiation exposure, and family history of cancer. Health care providers should identify cases of breast, ovarian, colon, prostate, pancreatic, and other types of germline mutation-associated cancer in first-degree, second-degree, and possibly third-degree relatives as well as the age of diagnosis. Women with a potentially increased risk of breast cancer based on initial history should have further risk assessment. Assessments can be conducted with one of the validated assessment tools available online, such as the Gail, BRCAPRO, Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm, International Breast Cancer Intervention Studies , or the Claus model 34.

Is screening breast self-examination recommended in women at average risk of breast cancer, and what should women do if they notice a change in one of their breasts?

Should practitioners perform routine screening clinical breast examinations in average-risk women?

When should screening mammography begin in average-risk women?

How frequently should screening mammography be performed in average-risk women?

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When Should I Start

A womans first mammogram serves as a baseline to compare results of subsequent mammograms.

  • Women should begin discussing breast cancer screening with their health care providers at age 40. From 40-44 years of age, women have the option to begin annual screening if they choose to do so. All women should begin yearly mammograms by age 45.
  • Women who are at higher risk for developing breast cancer, such as women with a family history of breast or ovarian cancer, should discuss their own personal risk factors with their health care providers, and may need to start screening earlier.

Should I Get A 3d Mammogram Or A 2d Mammogram

  • Digital 3D mammography , the latest technology used in mammography, takes multiple images of each breast from different angles. It has been shown to improve earlier detection of breast cancers and reduce the number of call backs for repeat imaging. 3D mammography is currently standard of care for women receiving mammograms at the Brigham.
  • Depending on personal risk factors, supplementary imaging tools such as breast ultrasound or breast magnetic resonance imaging may be appropriate.

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Breast Cancer Screening: Understanding The Guidelines

Approximately one in eight women will develop invasive breast cancer during her lifetime, according to the American Cancer Society . This post is designed to outline breast cancer screening guidelines.

Mammography is a very important screening tool for early breast cancer detection, but there are several different guidelines for when to start and how often to undergo mammography, says Dr. Giess. This can be confusing for many women.

The American College of Radiology recommends annual screening mammography beginning at age 40. The ACS guidelines emphasize screening based on a womans individual risk of developing breast cancer and her personal preferences.

American Cancer Society Screening Recommendations For Women At Average Breast Cancer Risk

Breast Cancer Screening Guidelines

The COVID-19 pandemic initially resulted in most elective procedures being put on hold, leading to many people not getting screened for cancer. Learn how you can talk to your doctor and what steps you can take to plan, schedule, and get your regular cancer screenings in Cancer Screening & COVID-19.

These guidelines are for women at average risk for breast cancer. For screening purposes, a woman is considered to be at average risk if she doesnt have a personal history of breast cancer, a strong family history of breast cancer, or a genetic mutation known to increase risk of breast cancer , and has not had chest radiation therapy before the age of 30.

  • Women between 40 and 44 have the option to start screening with a mammogram every year.
  • Women 45 to 54 should get mammograms every year.
  • Women 55 and older can switch to a mammogram every other year, or they can choose to continue yearly mammograms. Screening should continue as long as a woman is in good health and is expected to live at least 10 more years.
  • All women should understand what to expect when getting a mammogram for breast cancer screening what the test can and cannot do.

Clinical breast exams are not recommended for breast cancer screening among average-risk women at any age.

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Description Of The Evidence

Women at increased risk who may benefit more from screening

Women with BRCA1 and BRCA2 genetic mutations

Women with an increased risk of breast cancer caused by a BRCA1 or BRCA2 genetic mutation might benefit from increased screening. For more information, see Genetics of Breast and Gynecologic Cancers.

Recipients of thoracic radiation

Women with Hodgkin and non-Hodgkin lymphoma who were treated with mantle irradiation have an increased risk of breast cancer, starting 10 years after completing therapy and continuing life-long. Therefore, screening mammography has been advocated, even though it may begin at a relatively young age.

Individuals who benefit less from screening

Women with limited life expectancy

The potential benefits of screening mammography occur well after the examination, often many years later, whereas the harms occur immediately. Therefore, women with limited life expectancy and comorbidities who suffer harms may do so without benefit. Nonetheless, many of these women undergo screening mammography. In one study, approximately 9% of women with advanced cancer underwent cancer screening tests.

Older women

Screening mammography may yield cancer diagnoses in approximately 1% of women aged 66 to 79 years, but most of these cancers are low risk. The question remains whether the diagnosis and treatment of localized breast cancer in older women is beneficial.

Young women
Men
References

Breast Cancer Screening Update

On Monday, October 17, 2022, the Alberta Breast Cancer Screening Clinical Practice Guidelines1 were updated to help Albertans make informed decisions about breast cancer screening. The guidelines were last updated in 2013. Over the past nine years, more data and new scientific evidence have surfaced to support the update.

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How Often To Screen

Once a woman has decided to begin screening, the next decision is how often to undergo screening. No clinical trials compared annual mammography with a longer interval in women of any age. In the randomized trials that demonstrated the effectiveness of mammography in reducing breast cancer deaths in women aged 40 to 74 years, screening intervals ranged from 12 to 33 months.2, 3 There was no clear trend for greater benefit in trials of annual mammography, but other differences between the trials preclude certainty that no difference in benefit exists. Available observational evidence evaluating the effects of varying mammography intervals found no difference in the number of breast cancer deaths between women aged 50 years or older who were screened biennially versus annually.2, 3

Regardless of the starting age for screening, the models consistently predict a small incremental increase in the number of breast cancer deaths averted when moving from biennial to annual mammography, but also a large increase in the number of harms .7, 8 The USPSTF concludes that for most women, biennial mammography screening provides the best overall balance of benefit and harms.

The Minimum Age For Screening Has Been Lowered

Breast Cancer Screening

The key takeaway from the Alberta Health Services update is that the recommended age for starting biennial breast cancer screening for asymptomatic women, transgender, gender diverse, and non-binary people has been lowered from 50 to 45.

As committee Co-Chair Dr. Huiming Yang said, more evidence has become available to show net benefits of breast cancer screening at a younger age.6

Asymptomatic individuals are classified as average-risk. These people do not meet any criteria for higher-than-average or high risk, so they are considered average risk. Most of the public falls into this category.

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Screening In Women Aged 75 Years Or Older

The USPSTF found insufficient evidence to assess the balance of benefits and harms of screening mammography in women aged 75 years or older. CISNET models suggest that biennial mammography screening may potentially continue to offer a net benefit after age 74 years among women with no or low comorbidity,7, 8 but no randomized trials of screening included women in this age group.2, 3

Acog Revises Breast Cancer Screening Guidance: Ob

Washington, DCToday, The American College of Obstetricians and Gynecologists released its updated breast cancer screening guidance for average-risk women. ACOGs revised guidelines continue to underscore the importance of screening mammography and its role in early detection of breast cancer and consequent reduction in mortality. Among the changes, however, is an emphasis on patientprovider shared decision making to help women make informed, individualized decisions about when to start screening, the frequency of screening and when to end screening.

Our new guidance considers each individual patient and her values, said Christopher M. Zahn, M.D., ACOG Vice President of Practice Activities. Given the range of current recommendations, we have moved toward encouraging obstetriciangynecologists to help their patients make personal screening choices from a range of reasonable options.

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Recommendations On Other Screening Modalities Apart From Mammography:

  • We recommend not using magnetic resonance imaging , tomosynthesis or ultrasound to screen for breast cancer in women not at increased risk.
  • We recommend not performing clinical breast examinations to screen for breast cancer.
  • We recommend not advising women to practice breast self-examination to screen for breast cancer.

There was an absence of evidence on clinical outcomes of screening by magnetic resonance imaging, ultrasound, digital breast tomosynthesis or clinical breast examination, and there was evidence that performing breast self-examination has no impact on breast cancer mortality.

Dbt As A Primary Screening Strategy

Update on breast cancer screening guidelines

The USPSTF found insufficient evidence to assess the balance of benefits and harms of DBT as a primary screening method for breast cancer.

Background

Evidence on DBT is limited a single study on the test characteristics of DBT as a primary screening strategy for breast cancer met the inclusion criteria of the systematic evidence review.13

Potential Benefits

From the limited data available, DBT seems to reduce recall rates and increase cancer detection rates compared with conventional digital mammography alone.13 However, current study designs cannot determine whether all of the additional cases of cancer detected would have become clinically significant or whether there is an incremental clinical benefit to detecting these cancers earlier than with conventional digital mammography. In addition, no studies of DBT looked at clinical outcomes, such as breast cancer morbidity or mortality or quality of life.13

Potential Harms

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Strength Of Recommendations And Quality Of Evidence

17 of 23 guidelines reported eight applied grading systems. Grading of Recommendations, Assessment, Development and Evaluations was the common system that was applied in six guidelines . Four guidelines used the self-designated grading system . The details about the strength of recommendations and the quality of evidence varied in different grading systems. The information of evidence and recommendation about the included guidelines is shown in Table 2.

Summary Of Recommendations For Clinicians And Policy

Recommendations are presented for the use of mammography, magnetic resonance imaging, breast self exam and clinical breast exam to screen for breast cancer. These recommendations apply only to women at average risk of breast cancer aged 40 to 74 years. They do not apply to women at higher risk due to personal history of breast cancer, history of breast cancer in first degree relative, known BRCA1/BRCA2 mutation, or prior chest wall radiation. No recommendations are made for women aged 75 and older, given the lack of data.

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When To Start Screening

Clinical trials, observational studies, and modeling studies all demonstrate that the likelihood of avoiding a breast cancer death with regular screening mammography increases with age, and this increase in benefit likely occurs gradually rather than abruptly at any particular age. In contrast, the harms of screening mammography either remain constant or decrease with age. For example, about the same number of breast biopsies are performed as a result of screening mammography in women aged 40 to 49 years as in those aged 60 to 69 years, but many more of these biopsies will result in a diagnosis of invasive cancer in the older age group. Thus, the balance of benefit and harms improves with age .

It is, however, a false dichotomy to assume that the only options are to begin screening at age 40 or to wait until age 50 years. As women advance through their 40s, the incidence of breast cancer rises. The balance of benefit and harms may also shift accordingly over this decade, such that women in the latter half of the decade likely have a more favorable balance than women in the first half. Indeed, the CISNET models suggest that most of the benefit of screening women aged 40 to 49 years would be realized by starting screening at age 45.7, 8

The Screening Recommendations For Women At Higher Risk

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Risk factors of breast cancer identified in the guidelines mainly fell within five categories which could be broadly summarized as the personal history of pre-cancerous lesions and/or breast cancer the family history of breast cancer the known genetic predisposition of breast cancer the history of mantle or chest radiation therapy and dense breasts. For women at higher risk, there was a consensus among most guidelines that annual MAM screening or annual MRI screening should be given and the starting age should be earlier than the average-risk group .

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