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Breast Cancer Screening

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Sex- and Gender-Based Women's Health

Abstract

Breast cancer is the most common invasive cancer in women worldwide and is responsible for more deaths than any other cancer in women. There are multiple established risk factors for breast cancer, primarily involving genetics, radiation exposure, breast hyperplasia with atypia, and reproductive or hormonal factors. Screening mammography has been shown to reduce breast cancer mortality, and newer 3D mammography technology improves the sensitivity and specificity of mammography, particularly in women with dense breasts. Assessments of breast cancer risk in individual patients inform decisions regarding screening protocols, referrals to a breast health specialist, genetic testing, and consideration of prophylactic therapies. Professional organizations have varying guidelines regarding the initiation and frequency of screening mammography, but all agree that breast cancer screening should start no later than age 50. Women at high risk (>20–25% lifetime risk) for breast cancer, as determined using breast cancer risk prediction tools, should undergo yearly screening breast MRI in addition to mammography and be referred to a breast specialist to be evaluated for genetic testing and prophylactic therapies. High breast density (Breast Imaging Reporting and Data System or BI-RADS C and D) increases breast cancer risk; more data is needed to recommend for or against the routine use of ultrasounds or MRIs to screen women with increased breast density.

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Author information

Authors and Affiliations

  1. Department of Medicine, University of Washington and VA Puget Sound Healthcare System, Seattle, WA, USA

    Anna Golob, Traci A. Takahashi & Kay M. Johnson

Authors
  1. Anna Golob
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  2. Traci A. Takahashi
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  3. Kay M. Johnson
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Corresponding author

Correspondence to Anna Golob .

Editor information

Editors and Affiliations

  1. University of Pittsburgh School of Medicine, Division of General Internal Medicine, Department of Medicine, Pittsburgh, PA, USA

    Sarah A. Tilstra

  2. Harvard Medical School, Massachusetts General Hospital, Department of Medicine, Boston, MA, USA

    Deborah Kwolek

  3. Medical College of Wisconsin, Milwaukee, WI, USA

    Julie L. Mitchell

  4. Northwestern University Feinberg School of Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine, Chicago, IL, USA

    Brigid M. Dolan

  5. Hackensack Meridian School of Medicine at Seton Hall, Jersey Shore University Medical Center, Department of Medicine, Neptune, NJ, USA

    Michael P. Carson

Review Questions

Review Questions

  1. 1.

    A 40-year-old woman who is at average risk for breast cancer presents for a routine visit. After a thorough discussion of the risks and benefits of screening mammography, she says that she truly has no preference about when to start screening. She wants to know your recommendation. Based on recent guidelines, which screening strategy is most appropriate?

    1. A.

      Biennial screening mammography starting at age 55

    2. B.

      Annual screening mammography starting at age 40

    3. C.

      Annual screening mammography from 45 to 54, then biennial screening, or biennial screening starting at age 50

    4. D.

      Annual screening with mammography and breast MRI starting at age 40

    The correct answer is C. Answer C describes the recommended screening strategy for average-risk women per ACS and USPSTF, respectively. Answer A is incorrect because no organizations advise waiting until 55 to start screening. Answer B is incorrect because most organizations (except for the American College of Radiology) do not advise starting screening at age 40 for average-risk women, although it is an option. Answer D is incorrect because MRI is not indicated for average-risk women [5, 17].

  2. 2.

    A 50-year-old patient with an average risk for breast cancer based on careful review of personal and family history had her screening mammogram two weeks ago. She received a letter stating that, though the mammogram was normal, she has extremely dense breasts. It further states women with dense breasts have a higher risk of breast cancer than average, and she should talk with her doctor about possible supplemental screening. What is recommended?

    1. A.

      Order a breast MRI.

    2. B.

      Order a breast ultrasound.

    3. C.

      Refer to a breast health specialist for genetic counseling and testing.

    4. D.

      Tell her it’s unknown whether supplemental imaging improves survival in average-risk women with dense breasts and is not recommended.

    The correct answer is D. Explanation: The USPSTF concluded in its 2016 Breast Cancer Screening guidelines that there is insufficient evidence to assess the balance of benefits and harms of adjunctive screening using digital breast tomosynthesis, breast ultrasound, MRI, or other methods in women identified to have dense breasts on an otherwise negative mammogram. The other answer choices are incorrect because she is at average risk otherwise and so is not recommended to have supplemental screening with ultrasound and MRI or see a breast specialist [17].

  3. 3.

    A 42-year-old woman presents to establish care. Her family history is notable for breast cancer diagnosed in her mother at age 50 and her older sister at age 46 and ovarian cancer in a maternal aunt at age 55. She has never had a mammogram or other breast cancer screenings. As far as she knows, her family members have not had genetic testing for their cancers. What is the most appropriate tool to estimate her breast cancer risk?

    1. A.

      Tyrer-Cuzick (IBIS) tool.

    2. B.

      Gail Model (BCRAT).

    3. C.

      Atherosclerotic cardiovascular disease (ASCVD risk calculator).

    4. D.

      No tool is needed; proceed with average-risk screening.

    The correct answer is A. Explanation: This patient is clearly at high risk for a familial breast cancer syndrome; hence, the IBIS tool should be used as this has better risk prediction in patients with inherited breast cancer risk factors. The Gail Model (BRCAT) is not recommended when a familial breast cancer syndrome is strongly suspected. The ASCVD tool is not relevant, and it would be inappropriate to proceed with average-risk screening given her concerning family history [11].

  4. 4.

    A 42-year-old patient has an estimated lifetime risk of breast cancer of over 20% using the IBIS calculator. What is the next step regarding breast cancer screening?

    1. A.

      Annual 3D tomosynthesis mammography starting now

    2. B.

      Annual breast MRI in addition to annual mammography, genetic risk evaluation, and referral to a breast health specialist for consideration of prophylactic therapies

    3. C.

      Referral to a surgeon for consideration of prophylactic mastectomy and oophorectomy

    4. D.

      Biennial mammography starting at age 50

    The correct answer is B. Explanation: A patient with a lifetime risk of cancer which is >20% should be referred to a breast specialist and be considered for: annual MRI in addition to mammography screening (staggered by 6-month intervals), evaluation of genetic risk, and consideration for prophylactic therapies. The other answer choices are incorrect because mammography alone is not sufficient to screen women at high risk for breast cancer; and referral directly to a surgeon without genetic testing and consultation with a breast specialist would be premature [35].

  5. 5.

    A 39-year-old woman presents to her primary care provider with concerns for a new dime-sized lump in her right breast that she discovered incidentally while showering. The lump is not painful. She denies associated redness, fevers, or nipple discharge; she is not breastfeeding. She has never had a mammogram; no family history of breast or other cancers. On exam, her provider palpates a firm nontender nodule in the upper outer quadrant of her right breast without associated skin changes, nipple discharge, or lymphadenopathy. She is referred for a diagnostic mammogram, which is normal (BIRADS-1). What is the next step?

    1. A.

      Reassure her based on the normal diagnostic mammogram; no other testing is indicated.

    2. B.

      Advise her that she should have a repeat diagnostic mammogram in 6 months.

    3. C.

      Refer her to a breast surgeon for prophylactic mastectomy.

    4. D.

      Despite a negative mammogram, she should also have a diagnostic ultrasound with consideration of image-guided biopsy and referral to a breast health specialist.

    The correct answer is D. Explanation: Not all cancers are apparent on mammographic images. The rate of false negatives for screening mammography is reported between 10% and 30% and is highest in women with very dense breast tissue [45]. Palpable lumps must be fully evaluated with diagnostic mammogram, diagnostic ultrasound, consideration of image-guided biopsy, and referral to a breast health specialist. Answer choices A and B are incorrect because she needs further evaluation with diagnostic US and consideration of biopsy. Answer choice C is incorrect because a tissue diagnosis must be obtained to guide treatment decisions.

  6. 6.

    A 52-year-old patient with an average risk of breast cancer reports having a mammogram 2 years ago which was negative. She shares that having the mammogram was extremely uncomfortable and despite a detailed discussion about the benefits of mammography to screen for breast cancer and potential options to lessen discomfort, she is adamant about avoiding another. What other option, if any, could be offered to her?

    1. A.

      Breast MRI.

    2. B.

      Breast ultrasound.

    3. C.

      Clinical breast exam (CBE).

    4. D.

      No other options should be offered.

    The correct answer is C. Explanation: Currently, mammography is the only recommended breast cancer screening modality for average-risk women. Breast MRIs and ultrasounds are used as adjunctive imaging to mammography for diagnostic purposes and breast MRI is recommended for women at high risk for breast cancer screening. Patients can be offered a well-performed, systematic clinical breast exam (CBE) to assist with screening. While there is no evidence at this time that clinical breast exams reduce breast cancer mortality, a randomized trial comparing CBE to no screening in India will hopefully answer this question in the next several years [37]. There is some evidence that CBE can detect a substantial proportion of cases of cancer if it is the only screening test available [40].

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Golob, A., Takahashi, T.A., Johnson, K.M. (2020). Breast Cancer Screening. In: Tilstra, S.A., Kwolek, D., Mitchell, J.L., Dolan, B.M., Carson, M.P. (eds) Sex- and Gender-Based Women's Health. Springer, Cham. https://doi.org/10.1007/978-3-030-50695-7_18

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