Screening for Breast Cancer

This USPSTF recommendation was first published in:  Ann Intern Med 2002;137(Part 1):344-6. http://www.ahrq.gov/clinic/3rduspstf/breastcancer/brcanrr.htm.

Clinical Considerations

• The precise age at which the benefits from screening mammography justify the potential harms is a subjective judgment and should take into account patient preferences. Clinicians should inform women about the potential benefits (reduced chance of dying from breast cancer), potential harms (e.g., false-positive results, unnecessary biopsies), and limitations of the test that apply to women their age. Clinicians should tell women that the balance of benefits and potential harms of mammography improves with increasing age for women between the ages of 40 and 70.
• Women who are at increased risk for breast cancer (e.g., those with a family history of breast cancer in a mother or sister, a previous breast biopsy revealing atypical hyperplasia, or first childbirth after age 30) are more likely to benefit from regular mammography than women at lower risk. The recommendation for women to begin routine screening in their 40s is strengthened by a family history of breast cancer having been diagnosed before menopause.
• The USPSTF did not examine whether women should be screened for genetic mutations (e.g., BRCA1 and BRCA2) that increase the risk for developing breast cancer, or whether women with genetic mutations might benefit from earlier or more frequent screening for breast cancer.
• In the trials that demonstrated the effectiveness of mammography in lowering breast cancer mortality, screening was performed every 12-33 months. For women aged 50 and older, there is little evidence to suggest that annual mammography is more effective than mammography done every other year. For women aged 40-49, available trials also have not reported a clear advantage of annual mammography over biennial mammography. Nevertheless, some experts recommend annual mammography based on the lower sensitivity of the test and on evidence that tumors grow more rapidly in this age group.
• The precise age at which to discontinue screening mammography is uncertain. Only 2 randomized controlled trials enrolled women older than 69 and no trials enrolled women older than 74. Older women face a higher probability of developing and dying from breast cancer but also have a greater chance of dying from other causes. Women with comorbid conditions that limit their life expectancy are unlikely to benefit from screening.
• Clinicians should refer patients to mammography screening centers with proper accreditation and quality assurance standards to ensure accurate imaging and radiographic interpretation. Clinicians should adopt office systems to ensure timely and adequate followup of abnormal results. A listing of accredited facilities is available at www.fda.gov/cdrh/mammography/certified.html.
• Clinicians who advise women to perform BSE or who perform routine CBE to screen for breast cancer should understand that there is currently insufficient evidence to determine whether these practices affect breast cancer mortality, and that they are likely to increase the incidence of clinical assessments and biopsies.