Monday, October 4, 2010

Breast Cancer Awareness Month - ACS recommendations for early breast cancer detection


Earlier this year there was a lot of news regarding the recommended time frames for screenings for early breast cancer detection.  As someone who knows her personal risk for breast cancer I personally took the updated information "with a grain of salt"; I will continue to my screening schedule as I have been doing for over 10 years now.

However, I do know that many women who are unfamiliar with their personal risk were confused as to when should they start, etc.  For this reason, in today's post I am providing you with the American Cancer Society's recommendations for early screenings.  It is my understanding that these are the recommendations currently followed by most healthcare providers and insurers.

As with every post, I hope you find this information helpful!

American Cancer Society recommendations for early breast cancer detection in women without breast symptoms


Women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health.
  • Current evidence supporting mammograms is even stronger than in the past. In particular, recent evidence has confirmed that mammograms offer substantial benefit for women in their 40s. Women can feel confident about the benefits associated with regular mammograms for finding cancer early. However, mammograms also have limitations. A mammogram can miss some cancers, and it may lead to follow up of findings that are not cancer.
  • Women should be told about the benefits and limitations linked with yearly mammograms. But despite their limitations, mammograms are still a very effective and valuable tool for decreasing suffering and death from breast cancer. 
  • Mammograms should be continued regardless of a woman's age, as long as she does not have serious, chronic health problems such as congestive heart failure, end-stage renal disease, chronic obstructive pulmonary disease, and moderate to severe dementia. Age alone should not be the reason to stop having regular mammograms. Women with serious health problems or short life expectancies should discuss with their doctors whether to continue having mammograms. 
Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a periodic (regular) health exam by a health professional preferably every 3 years. Starting at age 40, women should have a CBE by a health professional every year.
  • CBE is done along with mammograms and offers a chance for women and their doctor or nurse to discuss changes in their breasts, early detection testing, and factors in the woman's history that might make her more likely to have breast cancer.  
  • There may be some benefit in having the CBE shortly before the mammogram. The exam should include instruction for the purpose of getting more familiar with your own breasts. Women should also be given information about the benefits and limitations of CBE and breast self-examination (BSE). The chance of breast cancer occurring is very low for women in their 20s and gradually increases with age. Women should be told to promptly report any new breast symptoms to a health professional.
Breast self-examination (BSE) is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away.
  • Research has shown that BSE plays a small role in finding breast cancer compared with finding a breast lump by chance or simply being aware of what is normal for each woman. Some women feel very comfortable doing BSE regularly (usually monthly after their period) which involves a systematic step-by-step approach to examining the look and feel of one's breasts. Other women are more comfortable simply feeling their breasts in a less systematic approach, such as while showering or getting dressed or doing an occasional thorough exam. Sometimes, women are so concerned about "doing it right" that they become stressed over the technique. Doing BSE regularly is one way for women to know how their breasts normally look and feel and to notice any changes. The goal, with or without BSE, is to report any breast changes to a doctor or nurse right away.  
  • Women who choose to use a step-by-step approach to BSE should have their BSE technique reviewed during their physical exam by a health professional. It is okay for women to choose not to do BSE or not to do it on a regular schedule such as once every month. However, by doing the exam regularly, you get to know how your breasts normally look and feel and you can more readily find any changes. If a change occurs, such as development of a lump or swelling, skin irritation or dimpling, nipple pain or retraction (turning inward), redness or scaliness of the nipple or breast skin, or a discharge other than breast milk (such as staining of your sheets or bra), you should see your health care professional as soon as possible for evaluation. Remember that most of the time, however, these breast changes are not cancer.

Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15% to 20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%.
Women at high risk include those who:
  • Have a known BRCA1 or BRCA2 gene mutation 
  • Have a first-degree relative (parent, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves 
  • Have a lifetime risk of breast cancer of 20% to 25% or greater, according to risk assessment tools that are based mainly on family history (see below) 
  • Had radiation therapy to the chest when they were between the ages of 10 and 30 years
  • Have Li-Fraumeni syndrome, Cowden syndrome, or hereditary diffuse gastric cancer syndrome, or have one of these syndromes in first-degree relatives

Women at moderately increased risk include those who:
  • Have a lifetime risk of breast cancer of 15% to 20%, according to risk assessment tools that are based mainly on family history (see below) 
  • Have a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH) 
  • Have extremely dense breasts or unevenly dense breasts when viewed by mammograms
If MRI is used, it should be in addition to, not instead of, a screening mammogram. This is because although an MRI is a more sensitive test (it's more likely to detect cancer than a mammogram), it may still miss some cancers that a mammogram would detect.

For most women at high risk, screening with MRI and mammograms should begin at age 30 years and continue for as long as a woman is in good health. But because the evidence is limited regarding the best age at which to start screening, this decision should be based on shared decision-making between patients and their health care providers, taking into account personal circumstances and preferences.

Several risk assessment tools, with names such as the Gail model, the Claus model, and the Tyrer-Cuzick model, are available to help health professionals estimate a woman's breast cancer risk. These tools give approximate, rather than precise, estimates of breast cancer risk based on different combinations of risk factors and different data sets. As a result, they may give different risk estimates for the same woman. Their results should be discussed by a woman and her doctor when being used to decide whether to start MRI screening.

It is recommended that women who get a screening MRI do so at a facility that can do an MRI-guided breast biopsy at the same time if needed. Otherwise, the woman will have to have a second MRI exam at another facility when she has the biopsy.

There is no evidence right now that MRI will be an effective screening tool for women at average risk. While MRI is more sensitive than mammograms, it also has a higher false-positive rate (it is more likely to find something that turns out not to be cancer). This would lead to unneeded biopsies and other tests in many of the women screened.

The American Cancer Society believes the use of mammograms, MRI (in women at high risk), clinical breast exams, and finding and reporting breast changes early, according to the recommendations outlined above, offers women the best chance to reduce their risk of dying from breast cancer. This approach is clearly better than any one exam or test alone. Without question, a physical exam of the breast without a mammogram would miss the opportunity to detect many breast cancers that are too small for a woman or her doctor to feel but can be seen on mammograms. Mammograms are a sensitive screening method, but a small percentage of breast cancers do not show up on mammograms but can be felt by a woman or her doctors. For women at high risk of breast cancer, such as those with BRCA gene mutations or a strong family history, both MRI and mammogram exams of the breast are recommended.

Last Medical Review: 09/15/2010

Last Revised: 09/15/2010
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