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Breast Cancer Screening Tool
Risk Factors:
 Age
 Postmenopausal hormone therapy
 Overweight or obesity, esp excessive weight
gain after menopause
 Use of alcohol, esp 1 or more daily
 Physical inactivity
 Long menstrual hx
 Previous chest radiation to tx different ca
 Personal history of breast cancer
 Biopsy-confirmed atypical hyperplasia
 Having a first child after age 30 or never
having children





number of first-degree relatives (mother,
sisters, daughters) with breast cancer
genetic predisposition such as being a
BRCA1/2 mutation carrier, or a genetic
syndromes such as Li-Fraumeni or Cowden
disease
To calculate individual’s Lifetime risk use Online Risk Assessment tools available @
http://www.cancer.gov/bcrisktool
A five-year risk of breast cancer of 1.66 % or
higher indicates high-risk status.
The following have been proven not to be risk factors for breast cancer or their effects on breast cancer risk are unknown:
 Abortion
 Diet
 Oral Contraceptives
 Active and passive cigarette smoking
 Environment
 Statins
Recommendations for Br Ca Screening w/ CBE & MGM:
Age, y
ACS
USPSTF*
NCI
20-39
CBE every 3 y (no
baseline MGM)
No recommendations
No data for benefit, nor for performing
baseline MGM
40-49
CBE & MGM yearly
MGM w/ or w/out CBE
every 1-2 yrs
MGM every 1-2 yrs (screening data
reviewed, value of CBE discussed, no
formal CBE recommendation)
50-69
CBE & MGM yearly
MGM every 1-2 yrs w/ or w/out CBE
≥ 70
Cessation of screening is
not age related but d/t co
morbidity
MGM w/ or w/out CBE
every 1-2 yrs
MGM w/ or w/out CBE
every 1-2 yrs, if life
expectancy is not
compromised by co
morbidity
High Risk
Most high-risk women
should begin getting MRIs
and mammograms at age
30, **see below
Screening may or not be helpful
Should talk with their health care
providers about whether to have
mammograms before age 40 and how
often to have them.
*Recommends women should be informed of potential benefits, limitations, and possible harms of mammography in making decisions about
when to begin screening.
Concludes that there is insufficient evidence to recommend for or against routine clinical breast examination alone to screen for breast cancer.
Concludes that there is insufficient evidence to recommend for or against teaching or performing routine breast self-examination.
** Women at increased risk of breast cancer might benefit from additional screening strategies beyond those offered to women of average risk,
such as earlier initiation of screening, shorter screening intervals, or the addition of screening modalities other than mammography and physical
examination, such as ultrasound or magnetic resonance imaging. However, the evidence currently available is insufficient to justify
recommendations for any of these screening approaches.
ACS Recommendations for Breast MRI Screening as an Adjunct to Mammography:
Recommend Annual MRI Screening
 BRCA mutation
 First-degree relative of BRCA carrier, but untested
 Lifetime risk ~20-25% or greater, as defined by BRCAPRO or other models that are largely dependent on family history
Recommend Annual MRI Screening
 Radiation to chest between age 10 and 30 years
 Li-Fraumeni syndrome and first-degree relatives
 Cowden and Bannayan-Riley-Ruvalcaba syndromes and first-degree relatives
Insufficient Evidence to Recommend for or Against MRI Screening





Lifetime risk 15-20%, as defined by BRCAPRO or other models that are largely dependent on family history
Lobular carcinoma in situ (LCIS) or atypical lobular hyperplasia (ALH)
Atypical ductal hyperplasia (ADH)
Heterogeneously or extremely dense breast on mammography
Women with a personal history of breast cancer, including ductal carcinoma in situ (DCIS)
Recommend Against MRI Screening
 Women at <15% lifetime risk
Sensitivity, Specificity & PPV
Sensitivity:
MRI= 71% & (young high risk women)= 71-100%> or <Mammography (young high risk women)=20-50% & (<40y)= 54-58% & (>65y)= 94%;
overall ~75%
Specificity:
Mammography= 90-95%> MRI= 90% (can vary from 37-97%)
PPV:
Mammography =20% (women<50 yo) & 60-80% (women 50-69 yo)
MRI= 43%
PPV increases w/ age:
 1-4 % among those 40-49 years of age,
 4-9 % among those 50-59 years of age,
 10-19 % among those 60-69 years of age,
 18-20% among those 70 years of age and older
Cost & Yield comparisons
Cost:
MRI= $600 - $3500 > US= $200- $300 > Mammography= $50-$150
Yields: (diagnostic)
MRI= 3.5% > Mammography=1.2% > US=0.
Statement of benefit
 Based on fair evidence, screening mammography in women aged 40 to 70 years decreases breast cancer mortality.
 The benefit is higher for older women, in part because their breast cancer risk is higher
Harms of Screening:
 Additional Interventions= Estimated to occur in 50% of women screened annually for 10 years, 25% of whom will have biopsies
 False Sense of Security= delay in cancer diagnosis (false-negatives)
 Radiation Exposure= Radiation-induced mutations can cause breast cancer, especially if exposed before age 30 years. Latency is more
than 10 years, and the increased risk persists lifelong
 Overdiagnosis= Treatment of insignificant cancers (overdiagnosis, true positives) can result in breast deformity, lymphedema,
thromboembolic events, new cancers, or chemotherapy-induced toxicities.
 Anxiety
Breast Imaging Reporting and Database System (BI-RADS):
Category
Assessment
Follow-up
0
Need additional imaging evaluation
Additional imaging needed before a category can be assigned
1
Negative
Continue annual screening mammography (for women over age 40)
2
Benign (noncancerous) finding
Continue annual screening mammography (for women over age 40)
3
Probably benign
Receive a 6-month follow-up mammogram
4
Suspicious abnormality
May require biopsy
5
Highly suggestive of malignancy (cancer)
Requires biopsy
6
Known biopsy-proven malignancy (cancer)
Biopsy confirms presence of cancer before treatment begins
Possible Mammogram Results & Follow-up care:
Conditions
Features
What a Provider might Recommend
Cysts
-Fluid-filled lumps
-Usually not cancer
-Occur most often in women ages 35-50
-Often in both breasts
-Some too small to be felt
-Ultrasound may be used to see whether a lump is solid or filled
with fluid.
-Providers often watch cysts over time or use fine-needle
aspiration to remove the fluid from the cyst.
Fibroadenoma
-Hard, round, benign growth
-Feels like rubber; moves around easily
-Usually painless
-Often found by the woman herself
-Appears on mammogram as smooth, round lumps
with clearly defined edges
-Can get bigger when the woman is pregnant or
nursing
-Sometimes diagnosed with fine-needle aspiration
-If the fibroadenoma does not appear normal, the doctor may
suggest taking it out to make sure it is benign
Macrocalcifications
-Appear on a mammogram as large calcium
deposits
-Often caused by aging
-Usually not cancer
-Have another mammogram to have a closer look at the area
-A biopsy may be used for diagnosis
Mass
Microcalcifications
-May be round and smooth or have irregular borders -A mammogram and/or ultrasound may be used to see whether a
-May be caused by normal hormone changes
lump is solid or filled with fluid
-A biopsy may be used for diagnosis
-Appear on a mammogram as tiny specks of
calcium that might be found in an area of rapidly
dividing cells
-If they are found grouped together in a certain way,
they may be a sign of cancer.
-Have another mammogram to have a closer look at the area
-A biopsy may be used for diagnosis
Types of Breast Cancer:
There are several types of breast cancer, although some of them are quite rare. It is not unusual for a single breast tumor to be a combination of
these types and to have a mixture of invasive and in situ cancer.
Ductal Carcinoma In Situ (DCIS)
Most common type of non-invasive breast cancer. Cancer cells are confined to the ducts but have not spread through the walls of the
ducts into surrounding breast tissue. ~1 in 5 new breast cancer cases will be DCIS. Most all women diagnosed at this early stage of breast cancer
can be cured. A mammogram is often the best way to find DCIS early.
Lobular Carcinoma In Situ (LCIS)
Not a true cancer, sometimes classified as a type of non-invasive breast cancer. Begins milk-producing glands but does not grow
lobule walls. Women with this condition have higher risk of developing an invasive breast cancer in the same breast or in the opposite breast. For
this reason, women with LCIS should pay close attention to having regular mammograms.
Invasive (or Infiltrating) Ductal Carcinoma (IDC)
Most common type of breast cancer. Starts in a duct of the breast, breaks through the wall of the duct, and invades the fatty tissue of
breast. May metastasize to other parts of the body through the lymph system and bloodstream. ~80% of invasive breast cancers are IDC.
Invasive (or Infiltrating) Lobular Carcinoma (ILC)
ILC starts in the lobules. It has the potential of metastasizing to other parts of the body. ~10% of invasive breast cancers are ILCs. ILC
may be harder to detect by a mammogram than IDC.
Less Common Types of Breast Cancer: Inflammatory breast cancer: Mixed tumors: Medullary cancer: Metaplastic carcinoma: Mucinous
carcinoma: Paget disease of the nipple:Tubular carcinoma: Papillary carcinoma: Adenoid cystic carcinoma (adenocystic carcinoma): Phyllodes
tumor: Angiosarcoma: