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Screening for breast cancer: Strategies and recommendations

Joann G Elmore, MD, MPH
Section Editor
Mark D Aronson, MD
Deputy Editor
Judith A Melin, MA, MD, FACP


Breast cancer is the most frequent type of non-skin cancer and the most frequent cause of cancer death in women worldwide, and the second most frequent cause of cancer death in United States women. (See "Clinical features, diagnosis, and staging of newly diagnosed breast cancer", section on 'Introduction' and "Clinical features, diagnosis, and staging of newly diagnosed breast cancer", section on 'Epidemiology' and "Diagnostic evaluation of women with suspected breast cancer", section on 'Introduction'.)

The majority of breast cancers in the United States are diagnosed as a result of an abnormal screening study, although a significant number are first brought to attention by a patient. Findings suggest that screening mammography both reduces the odds of dying of breast cancer and facilitates the use of early treatment. While the odds of dying of metastatic breast cancer are roughly one-third of what they were in the 1980s, it is thought that improvements in breast cancer treatment are more likely responsible for this reduction in mortality than screening [1-4].

Recommendations for breast cancer screening, taking into account the risk of developing breast cancer, other parameters that might affect screening decisions, and benefits and harms of screening, are discussed here.

Identification and management of 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 "Genetic counseling and testing for hereditary breast and ovarian cancer" and "Management of patients at high risk for breast and ovarian cancer" and "Approach to the patient following treatment for breast cancer".)

The evidence for the effectiveness and harms of screening for breast cancer in women, and performance characteristics of mammography, are discussed in detail separately. (See "Screening for breast cancer: Evidence for effectiveness and harms" and "Breast imaging for cancer screening: Mammography and ultrasonography".)

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Literature review current through: Nov 2017. | This topic last updated: Dec 10, 2017.
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  1. Welch HG, Prorok PC, O'Malley AJ, Kramer BS. Breast-Cancer Tumor Size, Overdiagnosis, and Mammography Screening Effectiveness. N Engl J Med 2016; 375:1438.
  2. Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med 2012; 367:1998.
  3. Autier P, Boniol M, Gavin A, Vatten LJ. Breast cancer mortality in neighbouring European countries with different levels of screening but similar access to treatment: trend analysis of WHO mortality database. BMJ 2011; 343:d4411.
  4. Harris R, Yeatts J, Kinsinger L. Breast cancer screening for women ages 50 to 69 years a systematic review of observational evidence. Prev Med 2011; 53:108.
  5. 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.
  6. 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.
  7. Breast cancer risk in American women. National Cancer Institute Web site. https://www.cancer.gov/types/breast/risk-fact-sheet. (Accessed on January 05, 2017).
  8. Chen S, Parmigiani G. Meta-analysis of BRCA1 and BRCA2 penetrance. J Clin Oncol 2007; 25:1329.
  9. 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.
  10. Benichou J, Gail MH, Mulvihill JJ. Graphs to estimate an individualized risk of breast cancer. J Clin Oncol 1996; 14:103.
  11. 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.
  12. Barlow WE, White E, Ballard-Barbash R, et al. Prospective breast cancer risk prediction model for women undergoing screening mammography. J Natl Cancer Inst 2006; 98:1204.
  13. Chen J, Pee D, Ayyagari R, et al. Projecting absolute invasive breast cancer risk in white women with a model that includes mammographic density. J Natl Cancer Inst 2006; 98:1215.
  14. Claus EB, Risch N, Thompson WD. Autosomal dominant inheritance of early-onset breast cancer. Implications for risk prediction. Cancer 1994; 73:643.
  15. Couch FJ, DeShano ML, Blackwood MA, et al. BRCA1 mutations in women attending clinics that evaluate the risk of breast cancer. N Engl J Med 1997; 336:1409.
  16. Shattuck-Eidens D, McClure M, Simard J, et al. A collaborative survey of 80 mutations in the BRCA1 breast and ovarian cancer susceptibility gene. Implications for presymptomatic testing and screening. JAMA 1995; 273:535.
  17. Frank TS, Manley SA, Olopade OI, et al. Sequence analysis of BRCA1 and BRCA2: correlation of mutations with family history and ovarian cancer risk. J Clin Oncol 1998; 16:2417.
  18. Parmigiani G, Berry D, Aguilar O. Determining carrier probabilities for breast cancer-susceptibility genes BRCA1 and BRCA2. Am J Hum Genet 1998; 62:145.
  19. Tyrer J, Duffy SW, Cuzick J. A breast cancer prediction model incorporating familial and personal risk factors. Stat Med 2004; 23:1111.
  20. Jacobi CE, de Bock GH, Siegerink B, van Asperen CJ. Differences and similarities in breast cancer risk assessment models in clinical practice: which model to choose? Breast Cancer Res Treat 2009; 115:381.
  21. Amir E, Freedman OC, Seruga B, Evans DG. Assessing women at high risk of breast cancer: a review of risk assessment models. J Natl Cancer Inst 2010; 102:680.
  22. Tice JA, Cummings SR, Smith-Bindman R, et al. Using clinical factors and mammographic breast density to estimate breast cancer risk: development and validation of a new predictive model. Ann Intern Med 2008; 148:337.
  23. Rockhill B, Spiegelman D, Byrne C, et al. Validation of the Gail et al. model of breast cancer risk prediction and implications for chemoprevention. J Natl Cancer Inst 2001; 93:358.
  24. Matsuno RK, Costantino JP, Ziegler RG, et al. Projecting individualized absolute invasive breast cancer risk in Asian and Pacific Islander American women. J Natl Cancer Inst 2011; 103:951.
  25. 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.
  26. 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.
  27. Gilpin CA, Carson N, Hunter AG. A preliminary validation of a family history assessment form to select women at risk for breast or ovarian cancer for referral to a genetics center. Clin Genet 2000; 58:299.
  28. Evans DG, Eccles DM, Rahman N, et al. A new scoring system for the chances of identifying a BRCA1/2 mutation outperforms existing models including BRCAPRO. J Med Genet 2004; 41:474.
  29. Bellcross CA, Lemke AA, Pape LS, et al. Evaluation of a breast/ovarian cancer genetics referral screening tool in a mammography population. Genet Med 2009; 11:783.
  30. Hoskins KF, Zwaagstra A, Ranz M. Validation of a tool for identifying women at high risk for hereditary breast cancer in population-based screening. Cancer 2006; 107:1769.
  31. Ashton-Prolla P, Giacomazzi J, Schmidt AV, et al. Development and validation of a simple questionnaire for the identification of hereditary breast cancer in primary care. BMC Cancer 2009; 9:283.
  32. Wacholder S, Hartge P, Prentice R, et al. Performance of common genetic variants in breast-cancer risk models. N Engl J Med 2010; 362:986.
  33. Mealiffe ME, Stokowski RP, Rhees BK, et al. Assessment of clinical validity of a breast cancer risk model combining genetic and clinical information. J Natl Cancer Inst 2010; 102:1618.
  34. Pharoah PD, Antoniou AC, Easton DF, Ponder BA. Polygenes, risk prediction, and targeted prevention of breast cancer. N Engl J Med 2008; 358:2796.
  35. 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.
  36. 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.
  37. Myers ER, Moorman P, Gierisch JM, et al. Benefits and Harms of Breast Cancer Screening: A Systematic Review. JAMA 2015; 314:1615.
  38. 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.
  39. 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.
  40. 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.
  41. Committee on Practice Bulletins—Gynecology. Practice Bulletin Number 179: Breast Cancer Risk Assessment and Screening in Average-Risk Women. Obstet Gynecol 2017; 130:e1.
  42. RACGP. Guidelines for preventive activities in general practice, breast cancer www.racgp.org.au/your-practice/guidelines/redbook/9-early-detection-of-cancers/93-breast-cancer/ (Accessed on December 05, 2017).
  43. NHS England Department of Health. Public health functions to be exercised by NHS England. Public Health Policy and Strategy Unit, Department of Health 2013 www.gov.uk/government/uploads/system/uploads/attachment_data/file/192971/S7A_VARIATION_2013-14_FINAL_130417.pdf (Accessed on December 05, 2017).
  44. American Academy of Family Physicians. Clinical Preventive Service Recommendation: Breast Cancer www.aafp.org/patient-care/clinical-recommendations/all/breast-cancer.html (Accessed on December 05, 2017).
  45. Mainiero MB, Lourenco A, Mahoney MC, et al. ACR Appropriateness Criteria Breast Cancer Screening. J Am Coll Radiol 2013; 10:11.
  46. NCCN Guidelines for Detection, Prevention, & Risk Reduction Breast Cancer Screening and Diagnosis https://www.nccn.org/store/login/login.aspx?ReturnURL=https://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf (Accessed on December 10, 2017).
  47. 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.
  48. American College of Obstetricians-Gynecologists. Practice bulletin no. 122: Breast cancer screening. Obstet Gynecol 2011; 118:372.
  49. 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.
  50. 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.
  51. NCI-funded Breast Cancer Surveillance Consortium (HHSN26121100031C) http://breastscreening.cancer.gov/. (Accessed on November 09, 2015).
  52. Keating NL, Pace LE. New Guidelines for Breast Cancer Screening in US Women. JAMA 2015; 314:1569.
  53. Miglioretti DL, Zhu W, Kerlikowske K, et al. Breast Tumor Prognostic Characteristics and Biennial vs Annual Mammography, Age, and Menopausal Status. JAMA Oncol 2015; 1:1069.
  54. American Academy of Family Physicians. clinical recommendations http://www.aafp.org/patient-care/clinical-recommendations/all/breast-cancer.html.
  55. 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.
  56. US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009; 151:716.
  57. Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA 2001; 285:2750.
  58. Walter LC, Schonberg MA. Screening mammography in older women: a review. JAMA 2014; 311:1336.
  59. 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.
  60. 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.
  61. 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.
  62. 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.
  63. 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.
  64. Smith-Bindman R, Kerlikowske K, Gebretsadik T, Newman J. Is screening mammography effective in elderly women? Am J Med 2000; 108:112.
  65. Breast Cancer Surveillance Consortium, funded by the National Cancer Institute http://breastscreening.cancer.gov/.
  66. Carney PA, Miglioretti DL, Yankaskas BC, et al. Individual and combined effects of age, breast density, and hormone replacement therapy use on the accuracy of screening mammography. Ann Intern Med 2003; 138:168.
  67. Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med 2005; 353:1773.
  68. Pisano ED, Hendrick RE, Yaffe MJ, et al. Diagnostic accuracy of digital versus film mammography: exploratory analysis of selected population subgroups in DMIST. Radiology 2008; 246:376.
  69. http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/FacilityScorecard/ucm113858.htm (Accessed on April 04, 2016).
  70. Tice JA, Ollendorf DA, Lee JM, Pearson SD. The Comparative Clinical Effectiveness and Value of Supplemental Screening Tests Following Negative Mammography in Women with Dense Breast Tissue, 2013. http://icer-review.org/sites/default/files/assessments/ctaf-final-report-dense-breast-imaging-11.04.2013-b.pdf (Accessed on July 15, 2015).
  71. 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.
  72. Drukteinis JS, Mooney BP, Flowers CI, Gatenby RA. Beyond mammography: new frontiers in breast cancer screening. Am J Med 2013; 126:472.
  73. Hooley RJ, Durand MA, Philpotts LE. Advances in Digital Breast Tomosynthesis. AJR Am J Roentgenol 2017; 208:256.
  74. 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).
  75. 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).
  76. 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.
  77. World Health Organization. Breast cancer: prevention and control; 2015. http://www.who.int/cancer/detection/breastcancer/en/ (Accessed on July 27, 2015).
  78. 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.
  79. 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).
  80. 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.
  81. 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.
  82. Berg CD. Breast Cancer Screening Interval: Risk Level May Matter. Ann Intern Med 2016; 165:737.
  83. 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.
  84. Melnikow J, Fenton JJ, Whitlock EP, et al. Supplemental Screening for Breast Cancer in Women With Dense Breasts: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med 2016; 164:268.
  85. Slanetz PJ, Freer PE, Birdwell RL. Breast-density legislation--practical considerations. N Engl J Med 2015; 372:593.
  86. Gartlehner G, Thaler K, Chapman A, et al. Mammography in combination with breast ultrasonography versus mammography for breast cancer screening in women at average risk. Cochrane Database Syst Rev 2013; :CD009632.
  87. 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.
  88. 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.
  89. 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.
  90. 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.
  91. Bjurstam N, Björneld L, Warwick J, et al. The Gothenburg Breast Screening Trial. Cancer 2003; 97:2387.
  92. 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.
  93. 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.
  94. Shapiro S. Periodic screening for breast cancer: the HIP Randomized Controlled Trial. Health Insurance Plan. J Natl Cancer Inst Monogr 1997; :27.
  95. Independent UK Panel on Breast Cancer Screening. The benefits and harms of breast cancer screening: an independent review. Lancet 2012; 380:1778.
  96. 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.
  97. Jørgensen KJ, Gøtzsche PC. Overdiagnosis in publicly organised mammography screening programmes: systematic review of incidence trends. BMJ 2009; 339:b2587.
  98. 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.
  99. 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.
  100. Hayse B, Hooley RJ, Killelea BK, et al. Breast cancer biology varies by method of detection and may contribute to overdiagnosis. Surgery 2016; 160:454.
  101. Jørgensen KJ, Gøtzsche PC, Kalager M, Zahl PH. Breast Cancer Screening in Denmark: A Cohort Study of Tumor Size and Overdiagnosis. Ann Intern Med 2017; 166:313.
  102. Segnan N, Minozzi S, Armaroli P, et al. Epidemiologic evidence of slow growing, nonprogressive or regressive breast cancer: A systematic review. Int J Cancer 2016; 139:554.
  103. Schousboe JT, Kerlikowske K, Loh A, Cummings SR. Personalizing mammography by breast density and other risk factors for breast cancer: analysis of health benefits and cost-effectiveness. Ann Intern Med 2011; 155:10.
  104. Hubbard RA, Kerlikowske K, Flowers CI, et al. Cumulative probability of false-positive recall or biopsy recommendation after 10 years of screening mammography: a cohort study. Ann Intern Med 2011; 155:481.
  105. Christiansen CL, Wang F, Barton MB, et al. Predicting the cumulative risk of false-positive mammograms. J Natl Cancer Inst 2000; 92:1657.
  106. NCI-funded Breast Cancer Surveillance Consortium (P01CA154292, U54CA163303, U01CA86076, U01CA63731, U01CA63740, U01CA70040, U01CA86082, U01CA70013). Downloaded 05/19/2017 from the Breast Cancer Surveillance Consortium Web site - http://www.bcsc-research.org/. http://www.bcsc-research.org/statistics/benchmarks/screening/2013/tableSensSpec.html (Accessed on May 19, 2017).
  107. Elmore JG, Barton MB, Moceri VM, et al. Ten-year risk of false positive screening mammograms and clinical breast examinations. N Engl J Med 1998; 338:1089.
  108. 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.
  109. Pace LE, Keating NL. A systematic assessment of benefits and risks to guide breast cancer screening decisions. JAMA 2014; 311:1327.
  110. Nekhlyudov L, Braddock CH 3rd. An approach to enhance communication about screening mammography in primary care. J Womens Health (Larchmt) 2009; 18:1403.
  111. 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.
  112. 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.
  113. 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.
  114. 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.
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