Breast: Breast Cancer Screening

Breast Examination

Self-Examination

  • Done by the Patient
  • NOT Recommended for Average Risk Women
  • Increased Rate of Unnecessary Biopsy for Benign Disease

Clinical Breast Examination

  • Done by Provider
  • Routine Screening Exam Not Recommended for Average Risk Women
  • Diagnostic Exam However Remains an Important Tool

Screening Mammogram

Basics

  • Mammographic Screening Decreases Mortality by 25%

Normal Risk

  • National Comprehensive Cancer Network (NCCN)
    • ≥ 40: Every Year
  • American College of Radiology
      • ≥ 40: Every Year
  • American Cancer Society
    • 40-44: Patient Preference
    • 45-54: Every Year
    • ≥ 55: Every 1-2 Years
  • US Preventative Services Task Force (USPSTF)
    • 40-49: Patient Preference
    • 50-74: Every 2 Years
    • ≥ 75: Insufficient Evidence

High-Risk (Lifetime > 20%)

  • Family Hx
    • Start: 10 Years Before Age of Dx in First Degree Relative
  • BRCA Positive
    • Yearly Breast MRI Starting at Age 25
      • Start Earlier if a First-Degree Relative Diagnosed < Age 30
    • Add Yearly Mammogram at Age 30
    • Also Include Pelvic Exam, US & CA-125

Post Mastectomy

  • Physical Exam:
    • Every 6 Months for 5 Years
    • Then Annually
  • No Screening Imaging Needed
  • Continue Routine Yearly Imaging for Contralateral Side if it Remains

Screening MRI

Indications for Annual MRI Screening

  • High-Risk (Lifetime Risk > 20%)
  • BRCA1 or BRCA2 Mutations
  • First-Degree Relative with BRCA Mutation, But Patient Untested
  • High-Risk Genetic Disease in Patient or a First-Degree Relative
    • Li-Fraumeni, PTEN, Cowden or Bannayan-Riley-Ruvalcaba Syndromes
  • Prior Chest Radiation Between Ages 10-30 Years

Insufficient Evidence – Decision Made on an Individual Basis

  • Moderate-Risk (Lifetime Risk 15-20%)
  • Personal History of Invasive Cancer
  • Carcinoma In-Situ (LCIS/DCIS)
  • Atypical Hyperplasia (ALH/ADH)
  • Heterogenous or Extremely Dense Breast Tissue on Mammogram

Genetic Screening

Genes Tested

  • BRCA1 & BRCA2
  • PALB2
  • PTEN
  • TP53
  • CDH1

Indications for Genetic Testing (NCCN Recommendations)

  • Known Family History of High-Risk Mutations (BRCA, etc.)
  • If Previously Tested Negative on a More Limited Test but Interested in Pursuing Multi-Gene Testing
  • Personal History of Cancer:
    • Breast Cancer:
      • Diagnosed at Age ≤ 45 Years
      • Diagnosed at Age 46-50 Years with:
        • Unknown or Limited Family History
        • A Second Breast Cancer at Any Age
        • ≥ 1 Close Relative with Breast, Ovarian, Pancreatic or Prostate Cancer
      • Diagnosed at Age ≤ 60 Years with Triple-Negative Breast Cancer
      • Diagnosed at Any Age with:
        • Ashkenazi Jewish Descent
        • ≥ 1 One Close Relative with:
          • Breast Cancer at Age ≤ 50
          • Ovarian or Pancreatic Cancer at Any Age
          • Metastatic, Intraductal/Cribriform Histology or High- or Very-High-Risk Group Prostate Cancer at Any Age
        • ≥ 3 Total Diagnoses of Breast Cancer in the Patient and/or Close Relatives
      • Male Breast Cancer at Any Age
    • Epithelial Ovarian Cancer (Including Fallopian Tube or Peritoneal Cancers) at Any Age
    • Exocrine Pancreatic Cancer at Any Age
    • Prostate Cancer at Any Age with:
      • Metastatic, Intraductal/Cribriform Histology or High- or Very-High-Risk Group
      • Ashkenazi Jewish Descent
      • ≥ 1 One Close Relative with:
        • Breast Cancer at Age ≤ 50
        • Ovarian or Pancreatic Cancer at Any Age
        • Metastatic, Intraductal/Cribriform Histology or High- or Very-High-Risk Group Prostate Cancer at Any Age
      • ≥ 2 Close Relatives with Either Breast or Prostate Cancer at Any Age
    • A Mutation Identified on Tumor Genomic Testing that has Clinical Implication if Also Identified in the Germline
    • If Meets Testing Criteria Otherwise for Li-Fraumeni Syndrome or Cowden/PTEN Hamartoma Tumor Syndrome
    • To Aid in Systemic Therapy Decision-Making, Such as HER2-Negative Metastatic Breast Cancer
  • Family History of Cancer:
    • An Individual with a First- or Second-Degree Relative Meeting Any of the Above Criteria (Except Individuals Who Meet Criteria Only for Systemic Therapy Decision Making)
      • If Affected Relative Has Pancreatic or Prostate Cancer, Only First-Degree Relatives Should Be Offered Testing Unless Indicated Otherwise
    • An Individual Who Otherwise Does Not Meet Criteria Above but Has a Probability > 5% of BRCA1/2 Mutation Based on Prior Probability Models
  • *Close Relatives: First, Second or Third-Degree

Possible Indications to Consider – Decision Made on an Individual Basis

  • Multiple Prior Breast Cancers, First Diagnosed Between Ages 50-65
  • Ashkenazi Jewish Descent without Other Indications
  • An Individual Who Otherwise Does Not Meet Criteria Above but Has a Probability 2.5-5% of BRCA1/2 Mutation Based on Prior Probability Models