When To Start Breast Cancer Screening

Where To Get Screened

Women ages 50 to 74 can call the nearest Ontario Breast Screening Program location to make an appointment .

Women in the North West and Hamilton Niagara Haldimand Brant regions may be eligible for screening in one of our mobile screening coaches.

If you think you may be at high risk for breast cancer, talk to your doctor about a referral to the High Risk Ontario Breast Screening Program based on family or medical history.

Breast Cancer Screening Guidelines And Recommendations

There are slightly conflicting guidelines and recommendations published by the leading experts in the field of breast cancer prevention. The major consensus groups offering guidelines are:

• The National Comprehensive Cancer Network
• The American College of Obstetricians and Gynecologists
• U.S. Preventive Services Task Force
• The American Cancer Society

Among these major consensus groups, notable differences in recommendations include:

• What age to start screening
• What age to stop screening
• How frequently to recommend mammography screening in average-risk women

According to the American Cancer Society Guidelines for the Early Detection of Cancer, the general recommendations are:

• Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so.
• Women ages 45 to 54 should get mammograms every year.
• Women ages 55 and older should switch to mammograms every two years or can continue yearly screening. Screening should continue as long as a woman is in good health and is expected to live ten more years or longer.
• All women should be familiar with the known benefits, limitations, and potential harms linked to breast cancer screening.

Women At Higher Risk Of Breast Cancer

Factors that greatly increase breast cancer risk include :

• A BRCA1 or BRCA2 inherited gene mutation
• A personal history of invasive breast cancer or ductal carcinoma in situ
• A personal history of lobular carcinoma in situ or atypical hyperplasia
• Radiation treatment to the chest area between ages 10-30
• Li-Fraumeni, Cowden/PTEN or Bannayan-Riley-Ruvalcaba syndrome
• An ATM, BARD1, BRIP1, CDH1, CHEK2, NBN, NF1, PALB2, PTEN, RAD51C, RAD51D, STK11 or TP53 inherited gene mutation
• A greater than 20 percent lifetime risk of invasive breast cancer based mainly on family history

Figure 3.5 below outlines the National Comprehensive Cancer Network breast cancer screening guidelines for women at higher than average risk up to age 75.

The NCCN recommends women older than 75 talk with their health care providers about a breast cancer screening plan thats right for them.

Figure 3.6 below outlines the American Cancer Society breast cancer screening guidelines for women at higher than average risk .

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Research Needs And Gaps

Trial data are too limited to directly inform the question of what the best screening strategy is for women or how clinicians can best tailor that strategy to the individual.

Overdiagnosis and resulting overtreatment of breast cancer that would otherwise not have become a threat to a womans health during her lifetime is the most important harm associated with breast cancer screening. Because it is impossible to determine for any individual patient whether a diagnosed cancer will or will not progress, measurements of overdiagnosis are not straightforward but rather are indirectly quantified. Current estimates of the magnitude of overdiagnosis associated with mammography screening vary widely. Researchers in the field must work together to critically evaluate and ultimately agree on uniform definitions and standards to optimally measure and monitor overdiagnosis and overtreatment in breast cancer screening programs.

Most of the available screening trials and high-quality cohort studies were performed in Europe and predominately enrolled white women younger than age 70 years. Direct evidence about any differential effectiveness of breast cancer screening is lacking for important subgroups of women, such as African American women, who are at increased risk for dying of breast cancer, and older women, for whom balancing the potential benefits and harms of screening may become increasingly challenging with advancing age.

Guidelines For Breast Cancer Screening

Breast cancer screening guidelines for average risk women have become confusing. One organization recommends that women start getting mammograms every other year at age 50 and another recommends yearly mammograms between age 45 and 55 with every other year mammograms thereafter. One reason for these differences is disagreement as to whether annual mammography in younger women can reduce the risk of dying of breast cancer. At Johns Hopkins, we continue to recommend annual mammography beginning at age 40 for average risk women,

Extra screening tests are recommended for women with higher than average risk for breast cancer. Current guidelines suggest that if you have more than a 20% risk of developing breast cancer during your lifetime you should consider adding screening breast MRI to your mammogram. Women who carry mutations in BRCA1, BRCA2, PALB2, or CHEK2 will meet this risk threshold. Other women with family history of breast cancer or a history of a breast biopsy showing high risk changes may meet this criterion as well. You can calculate your breast cancer risk online using the Gail model or the BCSC model . Breast specialists in the Johns Hopkins Breast Center have access to additional resources for calculating your breast cancer risk. At Johns Hopkins enhanced surveillance for high risk women consists of a breast exam every 6 months alternating mammograms with MRI scans.

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Update Of Previous Uspstf Recommendation

This recommendation updates the 2009 USPSTF recommendation on breast cancer screening with an assessment of the most current available scientific evidence for mammography screening. In addition, this update also provides additional clarity on what is meant by the C recommendation for women aged 40 to 49 years. A C recommendation is not a recommendation against mammography screening in this age group it signifies moderate certainty of a net benefit for screening that is small in magnitude. A C recommendation emphasizes that the decision to screen should be an individual one, made after a woman weighs the potential benefit against the possible harms. This recommendation also notes that women aged 40 to 49 years with a first-degree relative with breast cancer may potentially benefit more than average-risk women in this age group from beginning screening mammography before age 50 years.

This recommendation examines the evidence of the effectiveness of an emerging technologyDBTas a primary screening strategy. It also evaluates the effectiveness of adjunctive screening using ultrasonography, MRI, DBT, or other methods in women identified to have dense breasts on an otherwise negative mammogram.

The scope of the evidence review supporting this recommendation statement was determined after public comment on the draft research plan.

Breast Cancer Screening Recommendations

The United States Preventive Services Task Forceexternal icon is an organization made up of doctors and disease experts who look at research on the best way to prevent diseases and make recommendations on how doctors can help patients avoid diseases or find them early.

The USPSTFexternal icon recommends that women who are 50 to 74 years old and are at average risk for breast cancer get a mammogram every two years. Women who are 40 to 49 years old should talk to their doctor or other health care professional about when to start and how often to get a mammogram. Women should weigh the benefits and risks of screening tests when deciding whether to begin getting mammograms before age 50.

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What Is Breast Cancer Screening

Screening can help find breast cancer early, when it is easier to treat.

Breast cancer screeningexternal icon means checking a womans breasts for cancer before there are signs or symptoms of the disease. All women need to be informed by their health care provider about the best screening options for them. When you are told about the benefits and risks of screening and decide with your health care provider whether screening is right for youand if so, when to have itthis is called informed and shared decision-making.

Although breast cancer screening cannot prevent breast cancer, it can help find breast cancer early, when it is easier to treat. Talk to your doctor about which breast cancer screening tests are right for you, and when you should have them.

What Else Do You Need To Make Your Decision

Check the facts

• That’s right. The risk for breast cancer goes up as you get older. In general, women younger than 50 are at a lower risk for breast cancer.
• Sorry, that’s not right. The risk for breast cancer goes up as you get older. In general, women younger than 50 are at a lower risk for breast cancer.
• It may help to go back and read “Get the Facts.” The risk for breast cancer goes up as you get older. In general, women younger than 50 are at a lower risk for breast cancer.

• That’s right. Studies show that a small number of women who have mammograms may be less likely to die from breast cancer. Since the risk for breast cancer goes up as you get older, women ages 50 to 70 are more likely to benefit from having mammograms than women who are in their 40s.
• Sorry, that’s not right. Studies show that a small number of women who have mammograms may be less likely to die from breast cancer. Since the risk for breast cancer goes up as you get older, women ages 50 to 70 are more likely to benefit from having mammograms than women who are in their 40s.
• It may help to go back and read “Get the Facts.” Studies show that a small number of women who have mammograms may be less likely to die from breast cancer. Since the risk for breast cancer goes up as you get older, women ages 50 to 70 are more likely to benefit from having mammograms than women who are in their 40s.

Take a group of women who have a mammogram every year for 10 years .3

Understanding the evidence

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Take Control Of Your Health And Help Reduce Your Cancer Risk

• Stay away from all forms of tobacco.
• Get to and stay at a healthy weight.
• Get moving with regular physical activity.
• Eat healthy with plenty of fruits and vegetables.
• It’s best not to drink alcohol. If you do drink, have no more than 1 drink per day for women or 2 per day for men
• Protect your skin.
• Know yourself, your family history, and your risks.
• Get regular check-ups and cancer screening tests.

What Are Screening Tests

The goal of screening tests for breast cancer is to find it before it causes symptoms . Screening refers to tests and exams used to find a disease in people who dont have any symptoms. Early detection means finding and diagnosing a disease earlier than if youd waited for symptoms to start.

Breast cancers found during screening exams are more likely to be smaller and still confined to the breast. The size of a breast cancer and how far it has spread are some of the most important factors in predicting the prognosis of a woman with this disease.

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How Often Should You Have A Mammogram

What the ACP guidance says: Screening should be offered every other year from ages 50 to 74.

What else to consider: The ACP guidance is in line with that of the USPSTF, while the ACS says that screening should be done yearly starting at age 45, and every other year starting at age 55. The ACR recommends screening every year.

ACOG says that whether you have a screening every year or every two years should be a matter of preference, based on shared decision-making with your doctor. Keep in mind that the more frequently you get screened, the more likely you are to experience related harms such as overdiagnosis.

The Debate About When To Start Screening Mammograms

A number of large studies, including a review by the U.S. Preventive Services Task Force in 2009 and a study on the causes of death in the United Kingdom in 2013, have questioned the value of screening mammograms and ignited debate over when screening mammograms should start.

Public health experts who question the value of screening mammograms say that while mammograms do save lives, for each breast cancer death prevented, three to four women are overdiagnosed. Overdiagnosis means either:

• a screening mammogram finds a suspicious area that would have been eventually diagnosed as cancer by other means, without any effect on prognosis
• a screening mammogram finds a suspicious area that never would have affected a womans health if it hadnt been found or treated

False-positive results from screening mammograms also have helped fuel the debate about the value of breast cancer screening and when it should start. When a mammogram shows an abnormal area that looks like a cancer but turns out to be normal, its called a false positive. Ultimately the news is good: no breast cancer. But the suspicious area usually requires follow-up with more than one doctor, extra tests, and extra procedures, including a possible biopsy. There are psychological, physical, and economic costs that come with a false positive.

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Risks Of Mammography For Women Ages 40

Over-diagnosis and over-treatment are risks of mammography. Over-diagnosis and over-treatment occur when a mammogram finds a cancer that never would have caused symptoms or problems if it had never been diagnosed and had been left untreated.

Another drawback of mammography in women ages 40-49 is a high rate of false positive results .

Younger women are more likely than older women to have a false positive result on a mammogram. This is due to a number of reasons including the low number of breast cancers that occur in younger women and higher breast density in younger women.

Getting a false positive result means these women will be told they have an abnormal finding and undergo follow-up tests, only to find they dont have breast cancer. Follow-up tests may include a follow-up mammogram , breast ultrasound or even a biopsy.

American College Of Physicians Guidelines

A 2019 guidance statement from the American College of Physicians , based on a review of existing guidelines, addresses mammography in women at average risk, which is defined as the absence of the following:

• History of breast cancer or previous diagnosis of a high-risk lesion
• Genetic mutations such as BRCA1/2 or another familial breast cancer syndrome
• History of radiation therapy to the chest in childhood

The ACP provides the following recommendations to clinicians for breast cancer screening in average-risk women, according to age :

• Ages 40 to 49 years: Discuss whether to screen for breast cancer with mammography before age 50 years. The discussion should include the potential benefits and harms and the woman’s preferences. For most women in this age group, the potential harms outweigh the benefits.
• Ages 50 to 74 years: Offer screening for breast cancer with biennial mammography.
• Ages 75 years or older or in women with a life expectancy of 10 years or less: Discontinue screening for breast cancer.
• All ages: Do not use clinical breast examination to screen for breast cancer.

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If You Have A Family History Of Breast Cancer

UK guidelines recommend that women with a moderate or high risk of breast cancer because of their family history should start having screening mammograms every year in their forties.

If you are younger than 40 and have an increased risk of breast cancer, you should be offered yearly MRI scans from the age of 30 or 40. This depends on your level of risk.

Screening Guidelines For Women At Above

MSKs breast cancer experts have developed separate guidelines for women who have a higher-than-average breast cancer risk for the following reasons:

• family history of breast cancer in a first-degree relative
• history of atypical hyperplasia
• history of lobular carcinoma in situ
• history of mantle radiation before the age of 32
• genetic predisposition for breast cancer

If you have an above-average risk of breast cancer for the reasons listed above, MSK doctors recommend the guidelines below.

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Dbt As A Primary Screening Strategy

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

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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