Breast Cancer: Screening Guidelines

The National Cancer Institute estimates that there will be nearly 227,000 new cases of breast cancer diagnosed in the United States and nearly 40,000 deaths from the disease in 2012. The average American woman has a one in seven chance of developing breast cancer during her lifetime, based on a life expectancy of 85 years.

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. 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 or 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:

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. These include:

Breast Self Examination

During a breast self-examination (BSE), a woman 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 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 United States 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 cancers 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. Thus far, there are no data to establish that annual screening with ultrasound will reduce breast cancer mortality. However, there may be a subpopulation of high-risk women with dense breasts in whom the benefits outweigh the risks, and there is an ongoing multicenter study evaluating the use of ultrasound in this group. Currently, it is not the standard of care to offer or perform this examination.

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

  • Monthly breast self-examination (BSE) beginning at age 20 is optional. Awareness of breast changes is encouraged.
  • Annual clinical breast examination (CBE) beginning at age 25.
  • Annual mammography beginning at age 40.

Women with a Family History – i.e., One or More First-Degree Relative (Parent or Sibling)

  • Monthly BSE beginning at age 20 is optional. Awareness of breast changes is encouraged.
  • CBE every three to six months starting no later than ten years before the earliest diagnosis in the family.
  • Annual mammography starting ten years prior to the earliest diagnosis in the family (but not earlier than age 25 and not later than age 40).
  • Consider annual MRI. (Consider performing MRI and mammography at alternating six-month intervals. Consult with your physician.)

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

  • Monthly BSE beginning at age 20 is optional. Awareness of breast changes is encouraged.
  • CBE every three to six months
  • Annual mammography beginning at the time of diagnosis.
  • Consider annual MRI. (Consider performing MRI and mammography at alternating six-month intervals. Consult with your physician.)

Women with a History of Mantle Radiation

  • Monthly BSE beginning at age 20 is optional. Awareness of breast changes is encouraged.
  • CBE every three to six months beginning at the time of diagnosis.
  • Annual mammography starting eight years after radiation treatment.
  • Consider annual MRI.

For more information: National Comprehensive Cancer Network Breast Cancer Guidelines.