June 23rd, 2012 by Hasham

Screening Guidelines: Breast Cancer

In 2008, approximately 184,450 new cases of breast cancer will be diagnosed in the US, with approximately 41,000 individuals dying from the disease. The average American woman has a one in seven chance of developing breast cancer during her lifetime.

Studies have shown that regular screening of women with no symptoms has decreased the number of women who die from breast cancer by approximately 45 percent.

In the past, recommendations for breast cancer screening have been the same for women from different cancer-risk groups. However, due to the results of recent studies, Memorial Sloan-Kettering investigators have developed separate breast cancer screening guidelines for women at average risk and for those at increased risk because of familial and genetic predisposition.

In the sections below, we include a discussion of different screening tests and our doctors’ breast cancer screening guidelines, separated into four distinct risk categories.
Breast Cancer Risk Types
Average-risk women have:

* No symptoms
* No history of invasive breast cancer (breast cancers that have spread beyond the milk ducts, or lobules), ductal or lobular carcinoma in situ (cancers that are confined to the milk duct or lobule), or atypia, which is also known as atypical hyperplasia (a form of benign breast disease)
* No family history of breast cancer in a first degree relative (parent or sibling), or no suggestion/evidence of a hereditary syndrome
* No history of mantle radiation (a radiation therapy used to treat Hodgkin disease)

Above-average-risk women have any of the following:

* Family history of breast cancer (i.e. one first-degree relative — a parent or sibling — who had breast cancer)
* Diagnosis of atypia, also known as atypical hyperplasia (a form of benign breast disease), or lobular carcinoma in situ (cancers that are confined to the milk duct or lobule)
* History of having been treated with mantle radiation (a radiation therapy used to treat Hodgkin disease) before the age of 32

Breast Cancer Screening Tests

Breast cancer screening can involve a number of different types of examinations, which include breast self examination (BSE), clinical breast examination (CBE), mammography, magnetic resonance imaging (MRI), and ultrasound.
Breast Self-Examination

During a breast self-examination (BSE), a women checks her own breasts for any irregularities, which may include lumps, changes in breast size or shape, nipple discharge, or irregular tissue thickening. Despite attempts by investigators to demonstrate the impact of BSE on reducing breast cancer deaths, no study has been able to show a statistically significant reduction. As a result, our doctors and a number of national organizations no longer aggressively encourage women to perform BSE. However, because BSE is easy and free, and may detect some cancers, women are not discouraged from performing regular BSE.
Clinical Breast Examination

A clinical breast examination (CBE) is a physical examination of the breast performed by a health professional. In clinical studies where CBE was performed along with mammography, the reduction in deaths from breast cancer was similar to the reduction in those women who had received mammography alone. This suggests that CBE adds little to mammography in reducing breast cancer deaths.
Mammography

Mammography is the diagnostic examination of the breast using low-dose x-rays. Annual mammogram screenings have been shown to reduce significantly the number of women dying from breast cancer in the age group 40 years and older. Until fairly recently, all mammograms used the conventional film-based technique, which utilizes x-rays to produce an image of the breast on film. Introduced in the US in 2001, digital mammography also uses x-rays but captures the image on a computer, where it can be viewed and manipulated for contrast. While finding no significant difference between the two techniques when applied to the general population and for most women over 50, studies have shown that digital mammograms detected more tumors in three specific groups: women under 50, women with dense breasts, and women not yet in menopause.
Ultrasound

Ultrasound, also known as ultrasonography, is an imaging method in which high-frequency sound waves are used to create images of blood vessels, tissues, and organs including the breast. Breast ultrasound is often used to evaluate breast abnormalities that are found during mammography or a clinical breast exam. The accuracy of breast ultrasound is highly dependent on the skill level and training of the ultrasound technician. This creates an increased risk of false positives, requiring follow-up exams and biopsy — which can be expensive and lead to unnecessary anxiety for the patient.
Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is a diagnostic procedure that uses a magnetic field to provide three-dimensional images of internal body structures, including the breast. MRI is expensive and requires the injection of intravenous contrast dyes. Recent studies of women with an inherited risk of breast cancer have shown that MRI has a higher sensitivity in detecting breast cancers than other screening methods. However, there are no study data showing that MRI screening reduces the number of breast cancer deaths.
Our Breast Cancer Screening Guidelines

Our doctors recommend different breast cancer screening guidelines based on four distinct risk categories: women of average risk; women with at least one first-degree relative (i.e. parent or sibling) affected by breast cancer; women who have received a diagnosis of atypical hyperplasia (a form of benign breast disease) or lobular carcinoma in situ (cancers that are confined to the milk duct or lobule); and women with a history of mantle radiation (radiation received during treatment for Hodgkin disease).
Average Risk Women

Annual clinical breast examination (CBE) beginning at age 25
Annual mammography beginning at age 40
Women should be aware of any changes in their breasts. Monthly breast self-examination beginning at 20 years old is optional.

Women with a Family History of Breast Cancer — i.e., One or More First-Degree Relative (Parent or Sibling)
CBE every three to six months starting no later than ten years earlier than the age at which the youngest family member was diagnosed with breast cancer
Annual mammography starting ten years prior to the age of the youngest family member with breast cancer (but not earlier than age 25 and not later than age 40)
Consider annual MRI (consult with your physician)
Women should be aware of any changes in their breasts. Monthly breast self-examination beginning at 20 years old is optional.

Women with a Diagnosis of Atypical Hyperplasia or Lobular Carcinoma In Situ

* CBE every three to six months beginning at time of diagnosis
* Annual mammography beginning at the time of diagnosis
* Consider annual MRI (consult with your physician).
* Women should be aware of any changes in their breasts. Monthly breast self-examination beginning at 20 years old is optional.

Breast Cancer Screening Recommendations for Women at Higher Risk

Regular breast cancer screening is important for all women. If you are at higher risk of breast cancer, you may need to be screened earlier and more frequently than other women.

A woman is considered at higher risk if she has one factor that greatly increases her risk or several factors that together increase risk. Your health care provider may use different tools to assess your risk and help you make a breast cancer screening plan.

 Breast screening  Mammography

You’ll need to remove your clothes from the top part of your body, including your bra. The radiographer will then position you so that each breast in turn is placed on the x-ray machine and gently but firmly compressed (squashed) against a flat, clear, plastic plate.

The breast tissue needs to be compressed to keep the breast still, in order to get the clearest picture, using the lowest amount of radiation possible. Some women find the examination uncomfortable for a few seconds while the breast is being compressed. Only very few women find this painful. You’ll need to stay still for less than a minute while the picture is being taken. The radiographer takes two pictures of each breast, in two different positions, to make sure they examine all the breast tissue.
NHS Breast Screening Programme

In the UK, women aged 50–70 (64 in Northern Ireland) are invited to attend breast screening every three years as part of the NHS Breast Screening Programme. Each country within the UK has its own screening programme.

As part of the Government’s Cancer Reform Strategy (for England), the Department of Health plans to extend the age range for breast screening from 47–73 years. It aims for every woman to have their first breast screening before the age of 50. This age extension is gradually being introduced and is expected to be complete by 2016.

At the moment, if you’re 70 or over, you’re not automatically invited for breast screening. You can, however, make your own appointments| for free mammograms every three years if you wish.
MRI (magnetic resonance imaging)

MRI scanning is not generally used for breast screening on the NHS but is available for screening some women who are under 50 and at very high risk.

MRI scans use magnetism instead of x‑rays to build up a detailed picture of the breasts. During the scan, you’ll be asked to lie very still on a couch inside a long tube for about 30 minutes. It’s painless but can be uncomfortable, and some women feel a bit claustrophobic during the scan. It’s also noisy, but you’ll be given earplugs or headphones.

Some women are given an injection of dye into a vein in the arm, but this does not usually cause any discomfort.

Breast screening is a way of finding breast cancers| early, when they are too small for you or your doctor to see or feel. In the UK, around 1 in 9 women will develop breast cancer at some time in their life.

A woman with a significant family history| of the disease may carry a higher risk of developing breast cancer, but it’s important to remember that:

* most women don’t develop breast cancer – of those who do, most will not have a known family history of the disease
* for most women, increasing age is the greatest risk factor for developing breast cancer
* the majority of women with a family history of breast cancer don’t fall into a high-risk category and don’t develop breast cancer
* most women with a relative with breast cancer are not at a substantially increased risk of developing breast cancer themselves.

Each year, around one and a half million women in the UK have breast screening as part of the NHS Breast Screening Programme (NHSBSP). The NHSBSP is nationally coordinated and sets national standards.