Gynecology Book

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Breast Cancer Screening

Aka: Breast Cancer Screening, Screening for Breast Cancer
  1. See Also
    1. Breast Cancer Risk Factors
    2. Breast Cancer Gene Marker Testing Indications
  2. Efficacy: Breast Cancer Screening
    1. Overall
      1. Screening (especially Mammogram) contributed to 23% less mortality 1990-2000
      2. Berry (2005) N Engl J Med 353(17): 1784-92 [PubMed]
    2. Breast Self Exam
      1. Test Sensitivity: 12-41% of detected cancers
      2. Category D recommendation (not found as effective screening tool and may cause harm)
      3. See Self Breast Exam for details including efficacy
      4. Self Breast Exam is no longer routinely recommended due to low efficacy (see above)
        1. Does not lead to decreased Breast Cancer mortality
        2. High risk of false positives
      5. Consider a Breast self-awareness protocol as an alternative
        1. Women 20 years and older recognize normal appearance and feel of their Breasts (without systematic self-exam)
        2. Women who find new Breast changes should seek prompt medical attention
        3. McCready (2005) J Clin Nurs 14(5): 570-8 [PubMed]
    3. Clinical Breast Exam
      1. Test Sensitivity: 40-69% of detected cancers
      2. Test Specificity: 88-99%
    4. Mammogram
      1. Test Sensitivity: 77-95% of detected cancers
      2. Test Specificity: 94-97%
        1. Women under age 50 years have a false positive Mammogram rate nearly double that of women over age 50 years
      3. Number Needed to Screen to prevent a single Breast Cancer death
        1. Ages 39 to 49 years: 1904
        2. Ages 50 to 59 years: 1339
        3. Ages 60 to 69 years: 377
  3. Guidelines: Available Screening Modalities
    1. Standard modalities
      1. Breast Self Exam (BSE)
      2. Clinical Breast Examination (CBE)
      3. Mammogram
    2. High risk patients
      1. Breast Cancer Gene Marker (BRCA1 or BRCA2)
      2. Breast MRI
    3. Experimental
      1. Breast Specific Gamma Imaging (BSGI)
        1. New cardiolite-based modality
        2. Significantly improves on efficacy compared with old scintimammography
        3. Indicated in hyperdense Breasts or moderate risk patients not meeting criteria for Breast MRI
  4. Risk Factors: Breast Cancer Risk Assessment Tool
    1. See Breast Cancer Risk Factors
    2. Calculates 5 year and lifetime risk
    3. Based on most significant Breast Cancer Risk Factors
      1. Age, Menarche and age at first delivery
      2. Race and ethnicity
      3. First degree relatives with Breast Cancer
      4. Number of Breast biopsies and whether any had atypical hyperplasia
    4. Gail Model Breast Cancer Risk Calculator
      1. http://www.cancer.gov/bcrisktool/
  5. Guidelines: Low Risk Screening
    1. Ages 20-39 years
      1. Clinical Breast Examination (CBE) every 1-3 years
      2. Monthly Breast Self Exam (BSE) is no longer routinely recommended
        1. Consider a Breast self-awareness protocol as an alternative (see above)
    2. Age 40-49 years
      1. Clinical Breast Examination (CBE) every year
      2. Mammogram every 1-2 years (controversial)
        1. USPTF since 2009 has left screening age 40-50 up to provider and patient and in light of individual risk factors
          1. High mammogram False Positive Rate in women ages 40-50
          2. Number Needed to Screen to prevent one Breast Cancer death is much higher in younger women (see above)
        2. ACOG recommends annual Mammography for women aged 40-50 years old
          1. Lower Incidence of advanced cancer at diagnosis (younger women have more aggressive tumors)
          2. White (2004) J Natl Cancer Inst 96:1832-9 [PubMed]
      3. Monthly Breast Self Exam (BSE) is no longer routinely recommended
        1. Consider a Breast self-awareness protocol as an alternative (see above)
    3. Age 50 and over
      1. Clinical Breast Examination (CBE) every year
      2. Mammogram annually
        1. USPSTF Strength of Recommendation: A
      3. Monthly Breast Self Exam (BSE) is no longer routinely recommended
        1. Consider a Breast self-awareness protocol as an alternative (see above)
    4. Age 65 and over
      1. Clinical Breast Examination (CBE) every year
      2. Mammogram every 2 years
        1. Consider less frequent if reduced Life Expectancy
      3. Monthly Breast Self Exam (BSE) is no longer routinely recommended
        1. Consider a Breast self-awareness protocol as an alternative (see above)
      4. References
        1. Mandelblatt (2003) Ann Intern Med 139:835-42 [PubMed]
    5. Age to stop screening
      1. No guideline offers specific age, although many stop screening at age 75 years and older
      2. Reasonable to continue screening in otherwise healthy, elderly women
        1. American Geriatric Association recommends stopping screening when Life Expectancy <4 years
  6. Guidelines: Adjusted for Family History
    1. Strong Family History (Lifetime risk over 20%)
      1. Criteria
        1. One first degree relative with Breast Cancer OR
        2. Two distant relatives with Breast Cancer
      2. Screening Guidelines
        1. Clinical Breast Exam
          1. Annual exam for women over age 25 years
          2. Breast Exam every 6 months after age 30 years
        2. Mammogram
          1. Annually after age 35 years or
          2. Five years before youngest affected relative
        3. Breast MRI (consider)
          1. Annually starting at age 30 years
    2. High Risk (Lifetime Risk: 20-85%)
      1. See Breast Cancer Gene Marker Testing Indications
      2. Criteria
        1. Breast Cancer Gene Marker (BRCA1 or BRCA2) Carrier
        2. Known Breast Cancer Syndrome
        3. Very Strong Family History
          1. Two or more affected first degree relatives
            1. Breast Cancer
            2. Ovarian Cancer
          2. One first degree relative under age 40 years
          3. Affected premenopausal first degree relative
      3. Screening Guidelines
        1. Clinical Breast Exam
          1. Every 6 months after age 25 years
        2. Mammogram
          1. Annually after age 25 years
        3. Breast MRI
          1. Consider annually starting at age 30 years
  7. Guidelines: Adjusted for Past Medical History
    1. Atypical Hyperplasia
      1. Negative Family History (Lifetime Risk: 15-20%)
        1. Annual Clinical Breast Exam
        2. Annual Mammogram
      2. Positive Family History (Lifetime Risk over 20%)
        1. Clinical Breast Exam every 6 months
        2. Annual Mammogram: after age 40 or after diagnosis
        3. Breast MRI: Starting at age 30 years (consider)
    2. Lobular Carcinoma in situ (Lifetime Risk 20-30%)
      1. Clinical Breast Exam every 6 months
      2. Annual Mammogram after diagnosis
      3. Breast MRI: Consider starting at age 30 years
  8. References
    1. (1997) ACOG Opinion, no. 185
    2. Knutson (2007) Am Fam Physician 75:1600-6 [PubMed]
    3. Leitch (1997) CA Cancer J Clin 47:150-3 [PubMed]
    4. Smith (2000) CA Cancer J Clin 50:34-49 [PubMed]
    5. Tirona (2013) Am Fam Physician 87(4): 274-8 [PubMed]
    6. Woloshin (2010) JAMA 303(2): 160-1 [PubMed]
    7. Zoorob (2001) Am Fam Physician 63(6):1101-12 [PubMed]

Screening for malignant neoplasm of breast (C0281182)

Definition (NCI) Use of a device, marker, or other means for the purpose of detecting the presence of a breast tumor early in its development.
Definition (NCI) Early detection of breast cancer involving asymptomatic women. Generally done in the population with higher risk, due to environmental or genetic factors.
Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 268547008, 171174009, 148395005
English Breast neoplasm screen, Breast neoplasm screen NOS, Early Detection of Breast Cancer, Screening for malignant neoplasm of breast (procedure), Breast neoplasm screening, Breast neoplasm screening (procedure), Screening for malignant neoplasm of breast, breast screening for cancer, screening breast neoplasm, breast screening cancer, screening breast cancer, breast cancer screen, breast cancer detection early, early breast cancer detection, early detection breast cancer, screening for breast cancer, breast cancer early detection, breast cancer screening, early detection of breast cancer, Breast Cancer Screening, Breast Cancer Early Detection, Screening for Breast Cancer
Spanish detección selectiva de neoplasia de mama (procedimiento), cribaje para la detección de neoplasia de mama, rastreo para la detección de neoplasia de mama, tamizaje para la detección de neoplasia de mama, pesquisa para la detección de neoplasia de mama, screening para la detección de neoplasia de mama, cribado para la detección de neoplasia mamaria (procedimiento), screening de neoplasia de mama, tamizaje de neoplasia de mama, cribado para la detección de neoplasia mamaria, pesquisa de neoplasia de mama, detección selectiva para neoplasia de mama, cribado para la detección de neoplasia de mama, cribado de neoplasia de mama, detección selectiva de neoplasia de mama
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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