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BREAST CANCER

Population

  • Women.

Recommendations

USPSTF 2016

  • Age 40–49 y: Individualize assessment of breast cancer risk; incorporate woman’s preference and cancer risk profile to determine whether to screen.

  • Age ≥50–75 y: Mammography every 2 y, with or without clinical breast exam.

  • Age >75 y: Inconclusive data for screening.

ACS 2016

  • Age 20–40 y: Advise women to report lumps or breast symptoms.

  • Age 40–44 y: Allow women to begin annual screening if desired.

  • Age 45–54 y: Mammography every year.

  • Age ≥55 y: Mammography every 1–2 y as long as overall health is good and life expectancy is ≥10 y.

  • Do not use clinical breast examination for screening.

NCCN 2018

  • Age 25–40 y: Teach breast awareness.

  • Age 40–80 y: Mammography and clinical encounter annually.

  • Age >80 y: Do not screen.

Sources

Comments

  1. Harm and benefit of mammography screening

    1. Benefits: Based on fair evidence, screening mammography in women age 40–70 y decreases breast cancer mortality. The benefit is higher in older women (reduction in risk of death in women age 40–49 y = 15%–20%, 25%–30% in women age ≥50 y) but still remains controversial. (BMJ. 2014;348:366) (Ann Intern Med. 2009;151:727)

    2. Harms: Based on solid evidence, screening mammography may lead to potential harm by overdiagnosis (indolent tumors that are not life threatening) and unnecessary biopsies for benign disease. It is estimated that 20%–25% of diagnosed breast cancers are indolent and unlikely to be clinically significant. (CA Cancer J Clin. 2012;62:5) (Ann Intern Med. 2012;156:491)

    3. BSE does not improve breast cancer mortality (Br J Cancer. 2003;88:1047) and increases the rate of false-positive biopsies. (J Natl Cancer Inst. 2002;94:1445)

    4. Twenty-five percent of breast cancers diagnosed before age 40 y are attributable to BRCA1 or 2 mutations.

    5. The sensitivity of annual screening of young (age 30–49 y) high-risk women with magnetic resonance imaging (MRI) and mammography is superior to either alone, but MRI is associated with a significant increase in false positives. (Lancet. 2005;365:1769) (Lancet Oncol. 2011;378:1804)

    6. Computer-aided detection in screening mammography appears to reduce overall accuracy (by increasing false-positive rate), although it is more sensitive in women age <50 y with dense breasts. (N Engl J Med. 2007;356:1399)

    7. Digital mammography and film screen mammography have equal accuracy in women 50- to 79-y-old, but digital is more accurate in women 40- to 49-y-old. (Ann Intern Med. 2011;155:493)

    8. Estimated 252,710 new cases of invasive breast cancer (63,400 with DCIS) are expected in 2017, with 40,600 expected deaths. (NCI. 2017)

    9. Future cancer screening: circulating tumor DNA mutations have been identified that correlate with specific underlying malignancy. ...

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