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BREAST CANCER

Population

  • – Women.

Recommendations

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Consider screeninga

Screen regularly

Screening frequency

Stop screening

Include breast exam?

USPSTF 2016

40–49 y

50–75 y

Every 2 y

Inconclusive data age >75 y

Screen “with or without”

ACS 2016

40–44 y

≥45 y

Every year until 54 y, then every 1–2 y

Life expectancy <10 y

“Do not use”

NCCN 2019

40–80 y

Every year

>80 y

Yes

ACP 2019

40–49 y

50–74 y

Every 2 y

≥75 y or life expectancy <10 y

“Should not use”

ACOG 2017

40–49 y

50–75 y

Every 1–2 y

>75 y with shared decision making

“May be offered”

WHO 2014

40–49 only in well-resourced settings

50–75 y

Every 2 y

75 y

Only in low-resource settings

a Each guideline within this category makes a statement supporting an assessment of risk, often relying heavily upon family history, and eliciting patient preference to guide a discussion of risks and benefits to determine whether to screen.

Sources

Comments

  1. Harm and benefit of mammography screening

    1. Benefits: Based on fair evidence, screening mammography in women age 40–70 y decreases breast cancer mortality. The benefit is higher in older women (reduction in risk of death in women age 40–49 y = 15%–20%, 25%–30% in women age ≥50 y) but still remains controversial. (BMJ. 2014;348:366) (Ann Intern Med. 2009;151:727)

    2. Harms: Based on solid evidence, screening mammography may lead to potential harm by overdiagnosis (indolent tumors that are not life threatening) and unnecessary biopsies for benign disease. It is estimated that 20%–25% of diagnosed breast cancers are indolent and unlikely to be clinically significant. (CA Cancer J Clin. 2012;62:5) (Ann Intern Med. 2012;156:491)

    3. Clinical breast exam does not improve breast cancer mortality (Br J Cancer. 2003;88:1047) and increases the rate of false-positive biopsies. (J Natl Cancer Inst. 2002;94:1445)

    4. Twenty-five percent of breast cancers diagnosed before age 40 y are attributable to BRCA1 or 2 mutations.

    5. The sensitivity of annual screening of young (age 30–49 y) high-risk women with magnetic resonance imaging (MRI) and mammography is superior to either alone, but MRI is associated with a significant increase in false positives. (Lancet. 2005;365:1769) (Lancet Oncol. 2011;378:1804)

    6. Computer-aided detection in screening mammography appears to reduce overall accuracy (by increasing false-positive rate), although it is more sensitive in women age <50 y with dense breasts. (N Engl J Med. 2007;356:1399)

    7. Digital mammography and film screen mammography have equal accuracy in women 50- to 79-y-old, but ...

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