Breast Cancer          

Approximately 13% of American women will develop invasive breast cancer during their lifetime, with breast cancer being the second leading cause of cancer death.11,12 Patients older than 65 years, with known pathogenic genetic variations (eg, BRCA1, BRCA2, PALB2), or with a personal or family history of breast cancer are at highest risk of developing breast cancer.11,12 Other risk factors include increased breast tissue density, early menstruation (before age 11), late menopause (after age 55), lack of breastfeeding for at least 1 year, not having children or having children after age 30, and history of ductal carcinoma in situ or lobular carcinoma in situ.11,12 Potentially modifiable risk factors include overweight and obesity (for postmenopausal breast cancer), use of menopausal hormone therapy, recent use of hormonal contraceptives, alcohol consumptions, and physical inactivity.12 Due largely to advances in early cancer detection and treatment, the 5-year survival rate is over 90%.11,12 The standard of care in breast cancer screening is mammography. Other newer methodologies include magnetic resonance imaging (MRI), digital breast tomosynthesis, and ultrasound; however, there is a lack of consensus on using these technologies as part of a screening paradigm for women of average risk.12,13

Guideline recommendations vary with regard to frequency and age at which to begin and end screening for women at average risk of breast cancer (Table 3). ACOG recommends mammography every 1 to 2 years starting at age 40 with the option of an annual clinical breast exam.14 ACS recommends annual mammography in women aged 45 to 54 years, with the option to switch to biennial screening at age 55 and continue for as long as a woman is in good health and has a greater than 10-year life expectancy.15,16 For women aged 40 to 44 years, ACS recommends an individualized approach to screening with an option for annual mammography.15,16 The USPSTF recommends biennial mammography in women ages 50 to 74.17 This recommendation is based on a carefully researched risk-benefit analysis that showed the greatest breast cancer death reduction in women who were screened between the ages of 60 and 69 years, and the least benefit for those screened between the ages of 40 to 49 years.17

The greatest harms associated with screening mammograms are psychological distress associated with false-positive findings, overdiagnosis, and invasive follow-up testing.12 Owing in part to dense breast tissue, the risk of these potential harms is higher in younger women. 13 Providers must engage in shared decision-making, carefully reviewing potential harms and benefits to determine screening frequency and age to begin mammography.18


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Table 3. Breast Cancer Screening Guidelines

USPSTF15 (2016)ACS16 (2015)ACOG14 (2017)
Age 40 to 49 y: Women should make individual decisions and consult with their clinicians
Age 50-74 y: every 2 years
Age 40-44 y: optional
Age 45-54 y: annually
Age >55 y: every 1-2 years
Mammogram annually or biannually and starting age 40-50 y and ending at age 75 y based on shared decision-making
ACOG, American College of Obstetricians and Gynecologists; ACS, American Cancer Society; USPSTF, United States Preventative Services Task Force