Posted on 10 October 2014.
American Cancer Society recommendations for early breast cancer detection in women without breast symptoms
Women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health.
Current evidence supporting mammograms is even stronger than in the past. In particular, recent evidence has confirmed that mammograms offer substantial benefit for women in their 40s. Women can feel confident about the benefits associated with regular mammograms for finding cancer early. However, mammograms also have limitations. A mammogram can miss some cancers, and it may lead to follow up of findings that are not cancer.
Mammograms should be continued regardless of a woman’s age, as long as she does not have serious, chronic health problems such as congestive heart failure, end-stage renal disease, chronic obstructive pulmonary disease, and moderate to severe dementia. Women with serious health problems or short life expectancies should discuss with their doctors whether to continue having mammograms.
Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a periodic (regular) health exam by a health professional preferably every 3 years. Starting at age 40, women should have a CBE by a health professional every year.
CBE is done along with mammograms and offers a chance for women and their doctor or nurse to discuss changes in their breasts, early detection testing, and factors in the woman’s history that might make her more likely to have breast cancer. The chance of breast cancer occurring is very low for women in their 20s and gradually increases with age. Women should promptly report any new breast symptoms to a health professional.
Breast self-exam (BSE) is an option for women starting in their 20s. Women should report any breast changes to their health professional right away.
Research has shown that BSE plays a small role in finding breast cancer compared with finding a breast lump by chance or simply being aware of what is normal for each woman. Some women feel very comfortable doing BSE regularly (usually monthly after their period) which involves a systematic step-by-step approach to examining the look and feel of one’s breasts. Other women are more comfortable simply feeling their breasts in a less systematic approach, such as while showering or getting dressed or doing an occasional thorough exam.
Sometimes, women are so concerned about “doing it right” that they become stressed over the technique. Doing BSE regularly is one way for women to know how their breasts normally look and feel and to notice any changes. The goal, with or without BSE, is to report any breast changes to a doctor or nurse right away.
If a change occurs, such as development of a lump or swelling, skin irritation or dimpling, nipple pain or retraction (turning inward), redness or scaliness of the nipple or breast skin, or a discharge other than breast milk (such as staining of your sheets or bra), you should see your health care professional as soon as possible for evaluation. Remember that most of the time, however, these breast changes are not cancer.
Women who are at high risk for breast cancer based on certain factors should get an MRI and a mammogram every year.
This includes women who:
Have a lifetime risk of breast cancer of about 20 to 25 percent or greater, according to risk assessment tools that are based mainly on family history (such as the Claus model – see below)
Have a known BRCA1 or BRCA2 gene mutation.
Have a first-degree relative (parent, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves.
Had radiation therapy to the chest when they were between the ages of 10 and 30 years.
Have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes.
The American Cancer Society recommends against MRI screening for women whose lifetime risk of breast cancer is less than 15 percent.
There is not enough evidence to make a recommendation for or against yearly MRI screening for women who have a moderately increased risk of breast cancer (a lifetime risk of 15 to 20 percent according to risk assessment tools that are based mainly on family history) or who may be at increased risk of breast cancer based on certain factors, such as:
Having a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH)
Having dense breasts (“extremely” or “heterogeneously” dense) as seen on a mammogram.
If MRI is used, it should be in addition to, not instead of, a screening mammogram. This is because although an MRI is a more sensitive test (it’s more likely to detect cancer than a mammogram), it may still miss some cancers that a mammogram would detect.
For most women at high risk, screening with MRI and mammograms should begin at age 30 years and continue for as long as a woman is in good health. But because the evidence is limited about the best age at which to start screening, this decision should be based on shared decision-making between patients and their health care providers, taking into account personal circumstances and preferences.
There is no evidence right now that MRI is an effective screening tool for women at average risk. While MRI is more sensitive than mammograms, it also has a higher false-positive rate (it is more likely to find something that turns out not to be cancer). This would lead to unneeded biopsies and other tests in many of the women screened, which can lead to a lot of worry and anxiety.
The American Cancer Society believes the use of mammograms, MRI (in women at high risk), clinical breast exams, and finding and reporting breast changes early, according to the recommendations outlined above, offers women the best chance to reduce their risk of dying from breast cancer. This approach is clearly better than any one exam or test alone.
Without question, a physical exam of the breast without a mammogram would miss the opportunity to detect many breast cancers that are too small for a woman or her doctor to feel but can be seen on mammograms. Mammograms are a sensitive screening method, but a small percentage of breast cancers do not show up on mammograms but can be felt by a woman or her doctors. For women at high risk of breast cancer, such as those with BRCA gene mutations or a strong family history, both MRI and mammogram exams of the breast are recommended.