Breast Cancer Screening
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Early detection remains the primary way to prevent the development of life-threatening breast cancer. Breast cancers that are detected when smaller or nonpalpable are more treatable and thus are associated with a more favorable prognosis.
Imaging studies used in breast cancer screening include the following:
The survival benefit of early detection with mammography screening has been demonstrated. However, advances in imaging technology and disagreements over recommended schedules have complicated the issue of screening. As with any cancer screening program, careful consideration must be given to the risks of developing breast cancer as well as the benefits and harms of the screening intervention, along with the cost involved.
Early detection is widely endorsed by organizations that issue clinical recommendations for breast cancer care. Many expert groups have offered their recommendations for breast cancer screening, and much of the controversy lies in the fact that there is not a consensus about when to begin and end screening, how often to screen, and by what technique. These groups include the following;
For further information, see Breast Cancer and Breast Cancer Risk Factors. Also see Breast Lumps in Young Women: Diagnostic Approaches, a Critical Images slideshow, to help manage palpable breast lumps in young women.
For women younger than 40 years at average risk for breast cancer, there have no been randomized studies done to suggest a benefit to screening. The various experts groups have not reached a consensus among them, but several recommend a clinical breast exam (CBE) every 3 years and a discussion about the benefits and limitations of breast self exam (BSE).
For women over the age of 40 years at average risk for breast cancer, many expert groups recommend CBE annually. In terms of imaging, the most widely recommended screening approach in the United States for this group has been annual mammography. [1] The age at which to discontinue mammography has been a controversial subject, with some expert groups suggesting after age 75 [2] , while the American College of Radiology recommends annual screening mammography until the life expectancy is less than 5 to 7 years, based on comorbidities. [3]
Although mammography guidelines have been in place for over 30 years, 20-30% of women still do not undergo screening as indicated. The 2 most significant factors in determining whether a woman undergoes mammography are physician recommendation and access to health insurance. Non-white women and those of lower socioeconomic status remain less likely to obtain mammography services, and these women are more likely to present with life-threatening, advanced-stage disease.
In January 2016, the US Preventive Services Task Force (USPSTF) issued its final recommendations on breast cancer screening. [4, 2] The guidelines include the following:
The USPSTF recommends biennial screening mammography for women aged 50 to 74 years
No requirement for routine screening mammography in women aged 40-49 years (grade C recommendation); the decision to start regular, biennial screening mammography before age 50 years should be an individual one and should take into account patient context, including the patient’s values regarding specific benefits and harms
Insufficient current evidence to assess the additional benefits and harms of screening mammography in women aged 75 years or older
Insufficient current evidence to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as a screening modality for breast cancer
No requirement for clinicians to teach women how to perform BSE (grade D recommendation); this recommendation is based on studies that found that teaching BSE did not reduce breast cancer mortality but instead resulted in additional imaging procedures and biopsies
Insufficient current evidence to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women aged 40 years or older
The 2015 update of the American Cancer Society guidelines includes the following recommendations [5] :
The 2017 update of the American College of Obstetricians and Gynecologists guidelines on screening in average-risk women includes the following recommendations for practitioners [6] :
The NCCN on screening in average-risk women includes the following recommendations [7] :
NCCN guidelines provide four separate sets of recommendations for women at increased risk, on the basis of personal or family history, These include earlier initiation of mammography, in some cases, and consideration or recommendation of annual MRI. Additional considerations include the following:
An upper age limit for screening is not yet established. Consider severe comorbid conditions limiting life expectancy (eg, ≤10 years) and whether therapeutic interventions are planned.
For women with heterogeneous dense breasts and dense breast tissue, recommend counseling on the risks and benefits of supplemental screening.
Dense breasts limit the sensitivity of mammography and are associated with an increased risk for breast cancer.
Full-field digital mammography appears to benefit young women and women with dense breasts.
Multiple studies show that tomosynthesis can decrease callback rates and appears to improve cancer detection. Most studies used double the dose of radiation, but the radiation dose can be minimized by using synthesized 2-D reconstruction.
Hand-held or automated ultrasound can increase cancer detection, but may increase recall and benign breast biopsies.
Current evidence does not support the routine use of molecular imaging (eg, breast-specific gamma imaging, sestamibi scan, or positron emission mammography) as screening procedures, but emerging evidence suggests that these tests may improve detection of early breast cancers in women with mammographically dense breasts. However, the whole-body effective radiation dose with these tests is between 20 –30 times higher than that of mammography.
Current evidence does not support the routine use of thermography or ductal lavage as screening procedures.
Breast self-examination (BSE) and clinical breast examination (CBE) are inexpensive and noninvasive procedures for the regular examination of breasts (ie, monthly BSE and annual CBE). Evidence supporting the effectiveness of these 2 screening methods is controversial and largely inferred.
Even with appropriate training, BSE has not been found to reduce breast cancer mortality. In fact, the majority of the expert groups have revised their recommendations to include discussions about the benefits and limitations of this technique or a more general education about breast self-awareness. [7]
For example, ACOG distinguishes between BSE, which it does not recommend, from breast self-awareness, which it endorses. [6] Unlike BSE, breast self-awareness does not involve routine or systematic breast self-examination for the purpose of detecting breast cancer. Rather, it is a woman’s attunement to the normal appearance and feel of her breasts, so that she can notify her health care provider if she experiences breast changes such as pain, a mass, new onset of nipple discharge, or redness. [6]
With increasing improvements in treatment regimens for early, localized disease, CBE, particularly among women younger than 40 years, continues to be recommended by many groups, including ACOG and ACS. Randomized clinical trial results support combining CBE with mammography to enhance screening sensitivity, particularly in younger women in whom mammography may be less effective and in women who receive mammograms every other year as opposed to annually.
Mammography is a special type of low-dose x-ray imaging used to create detailed images of the breast. Mammography is currently the best available population-based method to detect breast cancer at an early stage, when treatment is most effective. Mammography can demonstrate microcalcifications smaller than 100 µm; it often reveals lesions before they become palpable by clinical breast examination (CBE) and, on average, 1-2 years before being found by breast self-examination (BSE). An estimated 48 million mammograms are performed each year in the United States.
The US Preventive Services Task Force (USPSTF) estimates the benefit of mammography in women aged 50-74 years to be a 30% reduction in risk of death from breast cancer. For women aged 40-49 years, the risk of death is decreased by 17%.
There are 2 types of mammography examinations: screening and diagnostic. Screening mammography is done in asymptomatic women. Diagnostic mammography is performed in symptomatic women (eg, when a breast lump or nipple discharge is found during self-examination or an abnormality is found during screening mammography). This examination is more involved, time-consuming, and expensive than screening mammography and is used to determine the exact size and location of breast abnormalities and to image the surrounding tissue and lymph nodes. Women with breast implants or a personal history of breast cancer will usually require the additional views used in diagnostic mammography.
The American College of Radiology (ACR) has established the Breast Imaging Reporting and Data System (BI-RADS) to guide the breast cancer diagnostic routine. BI-RADS is the product of a collaborative effort between members of various committees of the ACR in cooperation with the National Cancer Institute (NCI), the Centers for Disease Control and Prevention (CDC), the FDA, the American Medical Association (AMA), the American College of Surgeons (ACS), and the College of American Pathologists (CAP). [8]
The BI-RADS system includes categories or levels that are used to standardize interpretation of mammograms among radiologists. For referring physicians, the BI-RADS categories indicate the patient’s risk of malignancy and recommend a specific course of action.
Of all of the screening mammograms performed annually, approximately 90% show no evidence of cancer. On necessary further diagnostic testing, approximately 2% of all screening mammograms are shown to be abnormal and require biopsy. Among cases referred for biopsy, approximately 80% of the abnormalities are shown to be benign, and 20% are shown to be cancerous.
See Mammography in Breast Cancer for more information.
Mammographic sensitivity for breast cancer declines significantly with increasing breast density, and the risk of breast cancer is higher in women with dense breasts. Hormonal status has no significant effect on the effectiveness of screening independent of breast density.
Although mammography remains the most cost-effective approach for breast cancer screening, it is far from a perfect screening test, with a sensitivity of 76.5% and a specificity of 87.1% for women younger than 40 years. [9] By comparison, the sensitivity and specificity for mammography in women age 75-79 years is 88.4% and 93.5%, respectively. [10]
A retrospective trend analysis compared rates of breast cancer mortality in pairs of neighboring European countries where mammography screening had been implemented at different times. Findings suggest that mammography screening has little detectable impact on mortality due to breast cancer. [11]
Mammography uses low-dose ionizing radiation, which may be harmful to the patient. Nevertheless, the benefits of mammography far outweigh the risks and inconvenience.
False-positive results may arise when benign microcalcifications are regarded as malignant. Tissue summation shadows may appear as local parenchymal distortion; this may erroneously be called malignant tissue. A benign, circumscribed lesion may show signs suggestive of malignancy, along with other findings, such as an irregular border and no halo sign.
According to data from the Breast Cancer Detection Demonstration Project (BCDDP), the false-negative rate of mammography is approximately 8-10%. About 1-3% of women with a clinically suspicious abnormality, a negative mammogram, and a negative sonogram may still have breast cancer.
Possible causes for missed breast cancers include dense parenchyma obscuring a lesion, poor positioning or technique, perception error, incorrect interpretation of a suspect finding, subtle features of malignancy, and slow growth of a lesion.
Birdwell et al performed a multicenter study and found that on previous mammograms with missed cancers, 30% of the 115 lesions were calcifications, with 49% (17 of 35) clustered or pleomorphic. [12] Approximately 70% were mass lesions, with 40% spiculated or irregular. For calcifications and masses, the most frequently suggested reasons for possible miss were dense breasts (34%) and distracting lesions (44%).
Some cancers (eg, mucinous carcinomas) may have well-defined borders and mammographic features suggestive of a benign lesion.
A ductogram, or galactogram, is sometimes helpful for determining the cause of nipple discharge. In this specialized examination, a fine plastic tube is placed into the opening of the duct in the nipple. A small amount of contrast medium is injected, which outlines the shape of the duct on a mammogram, and shows whether a mass is present inside the duct.
Women with breasts augmented by implants may be a special challenge. Specific 4-view mammograms may be performed to evaluate the breasts; MRI may be especially useful for detecting breast cancer and silicon implant rupture in this group of patients.
See Postsurgical Breast Imaging for more information.
Ultrasonography has become a widely available and useful adjunct to mammography in the clinical setting. Ultrasound is generally used to assist the clinical examination of a suspicious lesion detected on mammography or physical examination. As a screening device, ultrasonography is limited by a number of factors, most notably by a failure to detect microcalcifications and by poor specificity (34%).
Originally, ultrasonography was used primarily as a relatively inexpensive and effective method of differentiating cystic breast masses, which did not require sampling, from solid breast masses that were usually examined with biopsy; in many cases, the results of these biopsies were benign. However, it is now well established that ultrasonography also provides valuable information about the nature and extent of solid masses and other breast lesions.
This imaging technique is also useful in the guidance of biopsies and therapeutic procedures; research is currently under way to evaluate its role in cancer screening.
Although mammography is an effective screening tool, data suggest that it is often less sensitive in detecting cancer in mammographically dense breast tissue. Kolb et al and Buchberger et al found that when performed carefully, ultrasonography may be useful in detecting occult breast cancer in dense breasts. [13, 14]
Ultrasonography is generally acknowledged to be a highly operator-dependent modality that requires a skilled practitioner, high-quality examinations, and state-of-the-art equipment. In view of the results of these studies, a prospective, multicenter study is clearly needed to examine the role of this imaging modality in breast cancer screening.
A large multicenter study supported by the Avon Foundation and the National Institutes of Health (NIH) was created through the American College of Radiology Imaging Network (ACRIN). [15] In this project, a protocol to assess the efficacy of screening breast ultrasonography is being implemented in 14 imaging centers to better define the role of this modality in breast cancer screening. (More information is available on the ACRIN Web site.)
In September 2012, the FDA approved the first ultrasound system, the somo-v Automated Breast Ultrasound System (ABUS), for breast cancer screening specifically in women with dense breast tissue. [16] ABUS is indicated as an adjunct to standard mammography for women with a negative mammogram, no breast cancer symptoms and no previous breast intervention such as surgery or biopsy.
Currently, it is recommended that ultrasonographic screening for breast disease be reserved for special situations, such as for highly anxious patients who request it and for women who have a history of mammographically occult carcinoma.
See Ultrasonography in Breast Cancer for more information.
In an effort to overcome the limitations of mammography and ultrasonography, MRI has been explored as a modality for detecting breast cancer in women at high risk and in younger women. A combination of T1, T2, and 3-D contrast-enhanced MRI techniques has been found to be highly sensitive (approximating 99% when combined with mammography and clinical breast examination) to malignant changes in the breast.
MRI has been demonstrated to be an important adjunct screening tool for women with BRCA1 or BRCA2 mutations, identifying cancers at earlier stages. However, breast MRI has limited use as a general screening tool, with a 10-fold higher cost than mammography and poor specificity (26%), resulting in significantly more false-positive reads that generate significant additional diagnostic costs and procedures.
According to the only study conducted to date using a control group, annual MRI-based screening among BRCA1 and BRCA2 carriers resulted in a significant 70% reduction in the hazard of developing stage II-IV (large or node-positive) invasive breast cancers (HR, 0.30; 95% CI, 0.12-0.71) compared to BRCA1 and BRCA2 carriers not undergoing annual MRI examinations. [17] Importantly, while the comparison group was instructed to undergo routine mammography screening, the majority of cancers were reported as self-detected. While these findings are not from a randomized setting and may suffer from unmeasured confounding that impacted the estimated effect of MRI, they provide support from a large population of BRCA1 and BRCA2 carriers for the beneficial use of MRI for the earlier detection of cancers.
Remaining unclear is the overall impact of earlier detection in this patient population on survival; a question that could not be addressed due to short follow-up.
For more information, see Magnetic Resonance Mammography.
The American Cancer Society (ACS) has established criteria for using breast MRI screening. [18] Based on evidence from nonrandomized trials and observational studies, the ACS recommends annual breast MRI screening in addition to mammography in patients with the following risk factors:
BRCA mutation
First-degree relative of BRCA carrier but untested
Lifetime risk approximately 20-25% or greater, as defined by BRCAPRO or other risk models
The ACS found insufficient evidence to recommend for or against MRI screening in patients with the following risk factors:
Lifetime risk 15-20%, as defined by BRCAPRO or other risk models
Lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), or atypical ductal hyperplasia (ADH)
Heterogeneously or extremely dense breast on mammography
Personal history of breast cancer, including ductal carcinoma in situ
The ACS does not recommend the use of breast MRI in women who have a less than 15% lifetime risk of breast cancer. For those with average risk, a combination of clinical breast examinations and yearly mammograms is recommended. For women who have a 15-20% lifetime risk of developing breast cancer, the ACS found insufficient evidence to recommend screening MRI.
The National Comprehensive Cancer Network (NCCN) guidelines on MRI screening differ from those of the ACS as follows [7] :
Annual MRI screening recommended in first-degree relatives of a BRCA carrier, but untested (encourage genetic testing before MRI)
Annual MRI screening is recommended for women with lifetime risk 20% or greater, as defined by models that are largely dependent on family history. Encourage genetic testing for first-degree relatives. If testing declined, recommend MRI.
Annual MRI screening is recommended for women who received radiation therapy to the chest when aged 10-30 years.
Annual MRI screening may be considered for women with a history of LCIS and ALH/ADH whose lifetime risk is ≥20%.
Advantages of MRI
The many advantages of breast MRI over conventional breast imaging for the detection of malignancy have become apparent with increasing clinical experience. These advantages include the following:
No ionizing radiation
All imaging planes possible
Capability of imaging the entire breast volume and chest wall
Superb 3-D lesion mapping with techniques such as maximum intensity projection (MIP) slab 3-D reconstruction
Greater than 90% sensitivity to invasive carcinoma
Detection of occult, multifocal, or residual malignancy
Accurate size estimation for invasive carcinoma
Good spatial resolution
Ability to image regional lymph nodes (although accurate staging remains problematic)
The widespread use of breast MRI for the detection of breast malignancy also has many disadvantages, as follows:
High equipment and examination costs
Limited scanner availability
Need for the injection of a contrast agent
No standard technique
Poor throughput compared with that of ultrasonography or mammography
Large number of images
Long learning curve for interpretation
False-positive enhancement in some benign tissues (limited specificity)
Variable enhancement of in situ carcinoma
A 5% incidence of slowly or poorly enhancing invasive carcinomas
Conversely, in a number of situations, MRI is essentially contraindicated, usually because of physical constraints that prevent adequate patient positioning. These constraints include the following:
Patient’s inability to lie prone
Marked kyphosis or kyphoscoliosis
Marked obesity
Extremely large breasts
Severe claustrophobia
Overview
What is breast cancer screening?
Which organizations have issued guidelines on breast cancer screening?
How are women screened for breast cancer?
What are the USPSTF guidelines for breast cancer screening?
What are the ACS guidelines on breast cancer screening?
What are the ACOG guidelines on breast cancer screening?
What are the NCCN guidelines on breast cancer screening?
What is the role of mammography in breast cancer screening?
What are the limitations of mammography for breast cancer screening?
What is the role of ductograms, or galactograms, in breast cancer screening?
How are women with breast implants screened for breast cancer?
What is the role of ultrasonography in breast cancer screening?
What is the role of MRI in breast cancer screening?
What are the ACS criteria for MRI in breast cancer screening?
What are the NCCN guidelines MRI in breast cancer screening?
What are the advantages of MRI for breast cancer screening?
What are the disadvantages of MRI for breast cancer screening?
When is MRI contraindicated in breast cancer screening?
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Warner E, Hill K, Causer P, Plewes D, Jong R, Yaffe M, et al. Prospective Study of Breast Cancer Incidence in Women With a BRCA1 or BRCA2 Mutation Under Surveillance With and Without Magnetic Resonance Imaging. J Clin Oncol. 2011 May 1. 29(13):1664-9. [Medline].
[Guideline] Saslow D, Boetes C, Burke W, Harms S, Leach MO, Lehman CD. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007 Mar-Apr. 57(2):75-89. [Medline].
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Erin V Newton, MD Assistant Professor of Clinical Medicine, Division of Hematology/Oncology, IU Simon Cancer Center, Indiana University School of Medicine; Staff Physician in Palliative Care, VA Medical Center
Erin V Newton, MD is a member of the following medical societies: American Society of Clinical Oncology, Multinational Association of Supportive Care in Cancer
Disclosure: Nothing to disclose.
Sara J Grethlein, MD Associate Dean for Undergraduate Medical Education, Indiana University School of Medicine
Sara J Grethlein, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Hematology, American Society of Clinical Oncology
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Marie Catherine Lee, MD, FACS Associate Professor, Department of Oncologic Sciences, Department of Surgery (Joint Appointment), University of South Florida Morsani College of Medicine; Associate Member, Comprehensive Breast Program, Moffitt McKinley Outpatient Center
Marie Catherine Lee, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Clinical Oncology, Association for Academic Surgery, Association of Women Surgeons, Florida Society of Clinical Oncology, Society of Surgical Oncology, Society of University Surgeons
Disclosure: Received research grant from: National Cancer Institute/National Institutes of Health; Department of Defense.
Robert C Shepard, MD, FACP Associate Professor of Medicine in Hematology and Oncology at University of North Carolina at Chapel Hill; Vice President of Scientific Affairs, Therapeutic Expertise, Oncology, at PRA International
Robert C Shepard, MD, FACP is a member of the following medical societies: American Association for Cancer Research, American Association for Physician Leadership, European Society for Medical Oncology, Association of Clinical Research Professionals, American Federation for Clinical Research, Eastern Cooperative Oncology Group, Society for Immunotherapy of Cancer, American Medical Informatics Association, American College of Physicians, American Federation for Medical Research, American Medical Association, American Society of Hematology, Massachusetts Medical Society
Disclosure: Nothing to disclose.
Leona Downey, MD Assistant Professor of Internal Medicine, Section of Oncology and Hematology, University of Arizona, Arizona Cancer Center
Leona Downey, MD is a member of the following medical societies: American Geriatrics Society, American Society of Clinical Oncology, and Southwest Oncology Group
Disclosure: Nothing to disclose.
Julie Lang, MD Associate Professor of Surgery, Norris Comprehensive Cancer Center, Keck School of Medicine of the University of Southern California
Julie Lang, MD is a member of the following medical societies: American College of Surgeons, American Society of Breast Surgeons, American Society of Clinical Oncology, Association for Academic Surgery, and Society of Surgical Oncology
Disclosure: Genomic Health, Grant/research funds, Speaking and teaching; Agendia, Grant/research funds, Speaking and teaching; Surgical Tools, Grant/research funds, Research; Sysmex, Grant/research funds, Research
Robert B Livingston, MD Professor of Clinical Medicine and Director, Clinical Research Shared Services, Arizona Cancer Center
Robert B Livingston, MD is a member of the following medical societies: American Association for Cancer Research, American Federation for Clinical Research, and American Society of Clinical Oncology
Disclosure: Nothing to disclose.
Alison T Stopeck, MD Professor of Medicine, Arizona Cancer Center, University of Arizona Health Sciences Center; Director of Clinical Breast Cancer Program, Arizona Cancer Center; Medical Director of Coagulation Laboratory, University Medical Center; Director of Arizona Hemophilia and Thrombosis Center
Alison T Stopeck, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Clinical Oncology, American Society of Hematology, Hemophilia and Thrombosis Research Society, and Southwest Oncology Group
Disclosure: Genentech Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; AstraZeneca Grant/research funds Other
Rachel Swart, MD, PhD Assistant Professor of Medicine, Department of Hematology and Oncology, Arizona Cancer Center, University of Arizona
Rachel Swart, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Society of Clinical Oncology, Arizona Medical Association, and Southwest Oncology Group
Disclosure: Roche Grant/research funds Other
Patricia A Thompson, PhD Assistant Professor, Department of Pathology, University of Arizona College of Medicine
Disclosure: Nothing to disclose.
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