So breast cancer screening is so
important and so controversial
that it really merits
its own discussion.
So I’m going to try to
talk about the guidelines
and recommendations for
breast cancer screening
and also impart some of
those controversial areas
that you can inform your patients about
because at the end of the day,
it’s about shared decision-making
and what the patient really wants in
terms of breast cancer prevention.
So let’s start with a case.
You’re seeing a 45-year-old woman, she
has no risk factors for breast cancer,
and she’s interested in initiating
breast cancer screening.
Which of the following
screening tools is the
most proven in reducing
breast cancer mortality?
Is it MRI, a clinical breast examination by
a physician or by a healthcare provider,
at home, or mammography?
The answer is mammography, and
mammography is not perfect,
but it certainly has the
strongest record of evidence
and probably the best balance
between picking up early tumors
and a lower false-positive rate,
and so we’ll talk about these things
as we move through the topic.
Breast examination certainly has a role.
Self-examination has been
demonstrated to increase
the number of radiographic studies ordered.
Patients come in, “I think I feel
something new on my breast,”
automatically going for a diagnostic
mammogram and an ultrasound.
And it also increases the
risk of getting biopsies,
so these are actual procedures
with potential complications,
but it hasn’t necessarily been demonstrated
to improve breast cancer mortality,
and therefore, it’s generally
discouraged certainly by organizations
such as US Preventive
Services Task Force.
A clinical breast examination
alone is insufficient
in terms of finding cancer
and therefore it can’t
But I do believe that personally it’s
better to do a clinical breast examination
before referring a patient to a mammogram
because you might be able to find some
abnormality or even just some degree of fibrosis
that you can tell the radiology
department to be on the watch for
and may change a screening mammogram
into a more diagnostic mammogram
and therefore a more accurate mammogram.
So certainly, try to do a clinical breast
examination before sending on a mammography.
So let’s think of another
facing us as we see this 45-year-old woman
without risk factors for breast cancer.
What should we recommend to her
regarding the USPSTF rules
for screening for breast cancer
among average-risk women?
Should screening definitely
be initiated by age 40?
Should it definitely be
initiated by age 50?
MRI should replace mammography
as the test of choice?
Or D, Routine mammography should
be continued until age 85?
And the answer is B, that screening
should definitely be initiated by age 50.
And here we start delve into some
of really the controversial issues
around breast cancer screening.
And it’s worth it I think
to use a graph like this,
which this is a graph
plotting the NNS
or number needed to screen to
prevent one breast cancer death.
So for among women between
the ages of 40 to 49,
about 1,900 women needed to be screened
to prevent one breast cancer death.
Meanwhile, many of these
women will be recalled
for abnormal exams,
that turn out to be
But extra testing, even some biopsies
that will be done, they are unnecessary.
So that’s one balance.
That number needed to screen
drops as women get older
to a little over 1,300 between
the ages 50 to 59 years.
But look what happens by the time
they hit 60 to 69 years of age.
That number drops precipitously.
And the risk of breast cancer is
really fairly linear with age,
so as women get older, therefore,
they do have a higher risk.
That’s what led the US Preventive
Services Task Force to
recommend against routine screening
between the ages of 40 and 49,
but that’s a hugely controversial call
and, therefore, it’s really
something that other societies
still recommend at least every
other year mammography,
if not annual mammography in the
period between ages 40 to 49 years.
And the least you want to do
is shared decision-making,
is explain that higher number needed
to screen among women aged 40 to 49,
the risk for false-positive
results is fairly high,
and therefore that’s something that
women need to be aware of.
But they also need to be aware that
tumors discovered between ages 40 to 49
when they’re cancerous also tend
to be more aggressive as well.
Then on the back end, there
isn’t as much to recommend
in terms of evidence screening
for breast cancer above age 75,
but the trend is clear
that the risk of cancer continuous
to grow as women grow older.
So therefore, I really would consider
it for breast cancer screening,
women who are older than 75 but have a
good five to ten-year life expectancy,
where it looks very positive;
they’re active, they’re healthy,
which is a large proportion of those women,
should be recommended at least to
consider continuing mammography.
And then in the last years of life, when
patients may be faced with conditions
such dementia or severe
that’s not a time to continue,
really, any cancer screening
But it remains a controversial area,
one that hopefully you’re
fairly informed about.
How often to screen?
In Europe, biannual screening
is generally the rule.
It’s more efficient overall in
identifying cases of breast cancer
and that it has a lower false-positive
rate and a lower number needed to screen.
But most US organizations continue to advocate
for annual screening for breast cancer.
Other considerations in
screening for breast cancer:
Ultrasound alone is not enough.
MRI does have an increased sensitivity,
but the sensitivity is actually too high
and therefore there are high
rates of false positive studies.
And so routine screening
with MRI is not recommended
and should be reserved only for
those women at the highest risk
of breast cancer as I mentioned.
And one other thing that’s a good pearl
that I’m not sure every student gets
is that in doing that
clinical breast examination,
when I find a new palpable lesion in
a woman who’s 50 years old or more,
not only would I recommend
and probably ultrasonography
at the same time,
but I’ll also do a concomitant
referral to a breast surgeon
because that case might need a tissue
diagnosis such as a fine-needle aspiration
in order to get an extra
level of security that
this indeed isn’t some
type of a cancerous tumor.
So we covered the controversial
issue of breast cancer screening
particularly the initiation and
termination of said screening
in a fairly brief and efficient way,
but I hope you found
it really helpful.
Thanks for paying attention.