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Screening for breast cancer: Strategies and recommendations

Author
Joann G Elmore, MD, MPH
Section Editor
Mark D Aronson, MD
Deputy Editor
Sadhna R Vora, MD

INTRODUCTION

There is more scientific evidence regarding screening for breast cancer, the most common nonskin cancer and second deadliest cancer in women, than for any other cancer. As with all cancer screening, recommendations for breast cancer screening rely on a combination of factors involving evidence about the risk of the condition, the benefits and harms of screening, and the cost.

When considering breast cancer screening, specific issues include determining who should be screened (risk stratification, age to begin screening, age to stop) and what method should be used for screening. As more information has become available about the occurrence of false-positive test results and overdiagnosis, and with increasingly more effective treatment for breast cancer, the trade-offs between benefits and harms of breast cancer screening have received increasing attention.

Recommendations for breast cancer screening, including breast cancer risk and other parameters that might affect screening decisions, are discussed here. These recommendations, based upon the evidence for screening for breast cancer in women, weigh benefits and harms of screening. Benefits and harms, in turn, will depend upon an individual's risk of developing and dying of breast cancer, how good the screening test is, how effective and tolerable the treatment is, and the woman's own personal values. The evidence for the effectiveness and harms of screening for breast cancer in women, performance characteristics of mammography, and patient risk stratification are discussed in detail separately. (See "Screening for breast cancer: Evidence for effectiveness and harms" and "Breast imaging for cancer screening: Mammography and ultrasonography" and "Risk prediction models for breast cancer screening".)

Discoveries of genetic mutations that increase the risk of breast cancer and the development of breast cancer risk prediction models have stimulated efforts to develop screening strategies stratified according to risk level. In tandem with mammography, breast magnetic resonance imaging (MRI) has been studied as a screening method for high-risk women. Management options for women with a genetic predisposition to breast cancer, and surveillance in women with a personal history of breast cancer, are discussed in detail separately. (See "Management of patients at high risk for breast and ovarian cancer" and "Approach to the patient following treatment for breast cancer".)

EPIDEMIOLOGY

Worldwide in 2013 there were about 1.8 million new cases of breast cancer and over 464,000 breast cancer deaths in women [1,2]. About one-half of breast cancer cases, and nearly 60 percent of breast cancer deaths, occur in women in less-developed countries [3]. In the United States, it is estimated that approximately 234,190 women will be diagnosed with invasive breast cancer, and 40,730 women will die from the disease in 2014 [4].

                              

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Literature review current through: Nov 2016. | This topic last updated: Fri Aug 26 00:00:00 GMT+00:00 2016.
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References
Top
  1. Global Burden of Disease Cancer Collaboration, Fitzmaurice C, Dicker D, et al. The Global Burden of Cancer 2013. JAMA Oncol 2015; 1:505.
  2. Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin 2011; 61:69.
  3. World Health Organization. Breast cancer: prevention and control. http://www.who.int/cancer/detection/breastcancer/en/index1.html (Accessed on January 08, 2014).
  4. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA Cancer J Clin 2015; 65:5.
  5. Jemal A, Simard EP, Dorell C, et al. Annual Report to the Nation on the Status of Cancer, 1975-2009, featuring the burden and trends in human papillomavirus(HPV)-associated cancers and HPV vaccination coverage levels. J Natl Cancer Inst 2013; 105:175.
  6. Kohler BA, Sherman RL, Howlader N, et al. Annual Report to the Nation on the Status of Cancer, 1975-2011, Featuring Incidence of Breast Cancer Subtypes by Race/Ethnicity, Poverty, and State. J Natl Cancer Inst 2015; 107:djv048.
  7. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA 2002; 288:321.
  8. McNeil C. Breast cancer decline mirrors fall in hormone use, spurs both debate and research. J Natl Cancer Inst 2007; 99:266.
  9. Chlebowski RT, Kuller LH, Prentice RL, et al. Breast cancer after use of estrogen plus progestin in postmenopausal women. N Engl J Med 2009; 360:573.
  10. Ravdin PM, Cronin KA, Howlader N, et al. The decrease in breast-cancer incidence in 2003 in the United States. N Engl J Med 2007; 356:1670.
  11. Glass AG, Lacey JV Jr, Carreon JD, Hoover RN. Breast cancer incidence, 1980-2006: combined roles of menopausal hormone therapy, screening mammography, and estrogen receptor status. J Natl Cancer Inst 2007; 99:1152.
  12. Johnson RH, Chien FL, Bleyer A. Incidence of breast cancer with distant involvement among women in the United States, 1976 to 2009. JAMA 2013; 309:800.
  13. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2006. CA Cancer J Clin 2006; 56:106.
  14. Centers for Disease Control and Prevention, U.S. Cancer statistics http://apps.nccd.cdc.gov/DCPC_INCA/DCPC_INCA.aspx (Accessed on March 11, 2014).
  15. Mittra I. Screening for breast cancer: is it globally applicable? Nat Clin Pract Oncol 2008; 5:60.
  16. Wong IO, Kuntz KM, Cowling BJ, et al. Cost effectiveness of mammography screening for Chinese women. Cancer 2007; 110:885.
  17. Smith RA, Caleffi M, Albert US, et al. Breast cancer in limited-resource countries: early detection and access to care. Breast J 2006; 12 Suppl 1:S16.
  18. Arslan AA, Formenti SC. Mammography in developing countries: the risks associated with globalizing the experiences of the Western world. Nat Clin Pract Oncol 2009; 6:136.
  19. Sabatino SA, White MC, Thompson TD, et al. Cancer screening test use - United States, 2013. MMWR Morb Mortal Wkly Rep 2015; 64:464.
  20. Nelson HD, Pappas M, Cantor A, et al. Harms of Breast Cancer Screening: Systematic Review to Update the 2009 U.S. Preventive Services Task Force Recommendation. Ann Intern Med 2016; 164:256.
  21. Nelson HD, Fu R, Cantor A, et al. Effectiveness of Breast Cancer Screening: Systematic Review and Meta-analysis to Update the 2009 U.S. Preventive Services Task Force Recommendation. Ann Intern Med 2016; 164:244.
  22. Miller AB, Wall C, Baines CJ, et al. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ 2014; 348:g366.
  23. Yen AM, Duffy SW, Chen TH, et al. Long-term incidence of breast cancer by trial arm in one county of the Swedish Two-County Trial of mammographic screening. Cancer 2012; 118:5728.
  24. Johns LE, Moss SM, Age Trial Management Group. False-positive results in the randomized controlled trial of mammographic screening from age 40 ("Age" trial). Cancer Epidemiol Biomarkers Prev 2010; 19:2758.
  25. Andersson I, Janzon L. Reduced breast cancer mortality in women under age 50: updated results from the Malmö Mammographic Screening Program. J Natl Cancer Inst Monogr 1997; :63.
  26. Bjurstam N, Björneld L, Warwick J, et al. The Gothenburg Breast Screening Trial. Cancer 2003; 97:2387.
  27. Alexander FE, Anderson TJ, Brown HK, et al. 14 years of follow-up from the Edinburgh randomised trial of breast-cancer screening. Lancet 1999; 353:1903.
  28. Frisell J, Lidbrink E. The Stockholm Mammographic Screening Trial: Risks and benefits in age group 40-49 years. J Natl Cancer Inst Monogr 1997; :49.
  29. Shapiro S. Periodic screening for breast cancer: the HIP Randomized Controlled Trial. Health Insurance Plan. J Natl Cancer Inst Monogr 1997; :27.
  30. Myers ER, Moorman P, Gierisch JM, et al. Benefits and Harms of Breast Cancer Screening: A Systematic Review. JAMA 2015; 314:1615.
  31. Kalager M, Zelen M, Langmark F, Adami HO. Effect of screening mammography on breast-cancer mortality in Norway. N Engl J Med 2010; 363:1203.
  32. Berry DA, Cronin KA, Plevritis SK, et al. Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 2005; 353:1784.
  33. Mandelblatt JS, Stout NK, Schechter CB, et al. Collaborative Modeling of the Benefits and Harms Associated With Different U.S. Breast Cancer Screening Strategies. Ann Intern Med 2016; 164:215.
  34. Armstrong K, Moye E, Williams S, et al. Screening mammography in women 40 to 49 years of age: a systematic review for the American College of Physicians. Ann Intern Med 2007; 146:516.
  35. Drukteinis JS, Mooney BP, Flowers CI, Gatenby RA. Beyond mammography: new frontiers in breast cancer screening. Am J Med 2013; 126:472.
  36. NCI-funded Breast Cancer Surveillance Consortium (HHSN26121100031C) http://breastscreening.cancer.gov/. (Accessed on November 09, 2015).
  37. Yankaskas BC, Haneuse S, Kapp JM, et al. Performance of first mammography examination in women younger than 40 years. J Natl Cancer Inst 2010; 102:692.
  38. Nelson HD, Tyne K, Naik A, et al. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med 2009; 151:727.
  39. American College of Obstetricians-Gynecologists. Practice bulletin no. 122: Breast cancer screening. Obstet Gynecol 2011; 118:372.
  40. Moss SM, Cuckle H, Evans A, et al. Effect of mammographic screening from age 40 years on breast cancer mortality at 10 years' follow-up: a randomised controlled trial. Lancet 2006; 368:2053.
  41. Salzmann P, Kerlikowske K, Phillips K. Cost-effectiveness of extending screening mammography guidelines to include women 40 to 49 years of age. Ann Intern Med 1997; 127:955.
  42. Randolph WM, Goodwin JS, Mahnken JD, Freeman JL. Regular mammography use is associated with elimination of age-related disparities in size and stage of breast cancer at diagnosis. Ann Intern Med 2002; 137:783.
  43. McCarthy EP, Burns RB, Freund KM, et al. Mammography use, breast cancer stage at diagnosis, and survival among older women. J Am Geriatr Soc 2000; 48:1226.
  44. Smith-Bindman R, Kerlikowske K, Gebretsadik T, Newman J. Is screening mammography effective in elderly women? Am J Med 2000; 108:112.
  45. van Dijck JA, Holland R, Verbeek AL, et al. Efficacy of mammographic screening of the elderly: a case-referent study in the Nijmegen program in The Netherlands. J Natl Cancer Inst 1994; 86:934.
  46. Van Dijck JA, Verbeek AL, Beex LV, et al. Mammographic screening after the age of 65 years: evidence for a reduction in breast cancer mortality. Int J Cancer 1996; 66:727.
  47. Schonberg MA, Silliman RA, Marcantonio ER. Weighing the benefits and burdens of mammography screening among women age 80 years or older. J Clin Oncol 2009; 27:1774.
  48. Lee SJ, Boscardin WJ, Stijacic-Cenzer I, et al. Time lag to benefit after screening for breast and colorectal cancer: meta-analysis of survival data from the United States, Sweden, United Kingdom, and Denmark. BMJ 2013; 346:e8441.
  49. Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA 2001; 285:2750.
  50. Miglioretti DL, Zhu W, Kerlikowske K, et al. Breast tumor prognostic characteristics and biennial vs annual mammography, age, and menopausal status. Jama Oncol 2015. http://oncology.jamanetwork.com/article.aspx?articleid=2456190 (Accessed on October 23, 2015).
  51. Kerlikowske K, Zhu W, Hubbard RA, et al. Outcomes of screening mammography by frequency, breast density, and postmenopausal hormone therapy. JAMA Intern Med 2013; 173:807.
  52. Trentham-Dietz A, Kerlikowske K, Stout NK, et al. Tailoring Breast Cancer Screening Intervals by Breast Density and Risk for Women Aged 50 Years or Older: Collaborative Modeling of Screening Outcomes. Ann Intern Med 2016; 165:700.
  53. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med 1997; 44:681.
  54. Pace LE, Keating NL. A systematic assessment of benefits and risks to guide breast cancer screening decisions. JAMA 2014; 311:1327.
  55. Nekhlyudov L, Braddock CH 3rd. An approach to enhance communication about screening mammography in primary care. J Womens Health (Larchmt) 2009; 18:1403.
  56. Onega T, Beaber EF, Sprague BL, et al. Breast cancer screening in an era of personalized regimens: a conceptual model and National Cancer Institute initiative for risk-based and preference-based approaches at a population level. Cancer 2014; 120:2955.
  57. Hoffman RM, Lewis CL, Pignone MP, et al. Decision-making processes for breast, colorectal, and prostate cancer screening: the DECISIONS survey. Med Decis Making 2010; 30:53S.
  58. Mandelblatt JS, Cronin KA, Bailey S, et al. Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms. Ann Intern Med 2009; 151:738.
  59. Coldman A, Phillips N. Incidence of breast cancer and estimates of overdiagnosis after the initiation of a population-based mammography screening program. CMAJ 2013; 185:E492.
  60. Etzioni R, Gulati R, Mallinger L, Mandelblatt J. Influence of study features and methods on overdiagnosis estimates in breast and prostate cancer screening. Ann Intern Med 2013; 158:831.
  61. Stacey D, Légaré F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014; :CD001431.
  62. Schonberg MA, Hamel MB, Davis RB, et al. Development and evaluation of a decision aid on mammography screening for women 75 years and older. JAMA Intern Med 2014; 174:417.
  63. Hersch J, Barratt A, Jansen J, et al. Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial. Lancet 2015; 385:1642.
  64. Nelson HD, Zakher B, Cantor A, et al. Risk factors for breast cancer for women aged 40 to 49 years: a systematic review and meta-analysis. Ann Intern Med 2012; 156:635.
  65. Gail MH, Costantino JP, Pee D, et al. Projecting individualized absolute invasive breast cancer risk in African American women. J Natl Cancer Inst 2007; 99:1782.
  66. Gail MH, Brinton LA, Byar DP, et al. Projecting individualized probabilities of developing breast cancer for white females who are being examined annually. J Natl Cancer Inst 1989; 81:1879.
  67. Nelson HD, Pappas M, Zakher B, et al. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: a systematic review to update the U.S. Preventive Services Task Force recommendation. Ann Intern Med 2014; 160:255.
  68. Moyer VA, U.S. Preventive Services Task Force. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014; 160:271.
  69. Elmore JG, Reisch LM, Barton MB, et al. Efficacy of breast cancer screening in the community according to risk level. J Natl Cancer Inst 2005; 97:1035.
  70. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007; 57:75.
  71. Liberman L. Breast cancer screening with MRI--what are the data for patients at high risk? N Engl J Med 2004; 351:497.
  72. Kuhl CK, Schrading S, Leutner CC, et al. Mammography, breast ultrasound, and magnetic resonance imaging for surveillance of women at high familial risk for breast cancer. J Clin Oncol 2005; 23:8469.
  73. Berg WA, Blume JD, Cormack JB, et al. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. JAMA 2008; 299:2151.
  74. National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27, 2016).
  75. Pharoah PD, Antoniou AC, Easton DF, Ponder BA. Polygenes, risk prediction, and targeted prevention of breast cancer. N Engl J Med 2008; 358:2796.
  76. Mainiero MB, Lourenco A, Mahoney MC, et al. ACR Appropriateness Criteria Breast Cancer Screening. J Am Coll Radiol 2013; 10:11.
  77. Lee CH, Dershaw DD, Kopans D, et al. Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol 2010; 7:18.
  78. Bevers TB, Anderson BO, Bonaccio E, et al. NCCN clinical practice guidelines in oncology: breast cancer screening and diagnosis. J Natl Compr Canc Netw 2009; 7:1060.
  79. Oeffinger KC, Fontham ET, Etzioni R, et al. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society. JAMA 2015; 314:1599.
  80. Canadian Task Force on Preventive Health Care, Tonelli M, Connor Gorber S, et al. Recommendations on screening for breast cancer in average-risk women aged 40-74 years. CMAJ 2011; 183:1991.
  81. American Academy of Family Physicians. clinical recommendations http://www.aafp.org/patient-care/clinical-recommendations/all/breast-cancer.html.
  82. Wilt TJ, Harris RP, Qaseem A, High Value Care Task Force of the American College of Physicians. Screening for cancer: advice for high-value care from the American College of Physicians. Ann Intern Med 2015; 162:718.
  83. Qaseem A, Snow V, Sherif K, et al. Screening mammography for women 40 to 49 years of age: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2007; 146:511.
  84. Siu AL, U.S. Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2016; 164:279.
  85. US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009; 151:716.
  86. Feig SA, D'Orsi CJ, Hendrick RE, et al. American College of Radiology guidelines for breast cancer screening. AJR Am J Roentgenol 1998; 171:29.
  87. van Ravesteyn NT, Miglioretti DL, Stout NK, et al. Tipping the balance of benefits and harms to favor screening mammography starting at age 40 years: a comparative modeling study of risk. Ann Intern Med 2012; 156:609.
  88. WHO position paper on mammography screening. World Health Organization; 2014. http://apps.who.int/iris/bitstream/10665/137339/1/9789241507936_eng.pdf?ua=1&ua=1 (Accessed on July 27, 2015).
  89. Screening for Breast Cancer, Geneva: World Health Organization, 2009. Available at: http://www.who.int/cancer/detection/breastcancer/en/index.html (Accessed on November 24, 2009).
  90. Smith RA, Saslow D, Sawyer KA, et al. American Cancer Society guidelines for breast cancer screening: update 2003. CA Cancer J Clin 2003; 53:141.
  91. World Health Organization. Breast cancer: prevention and control; 2015. http://www.who.int/cancer/detection/breastcancer/en/ (Accessed on July 27, 2015).
  92. National Institute for Health and Care Excellence. Familial breast cancer: classification and care of people at risk of familial breast cancer and management of breast cancer and related risks in people with a family history of breast cancer. www.nice.org.uk/guidance/CG164 (Accessed on March 24, 2014).