Risk-Based Breast Cancer Screening Guidelines from the American Society of Breast Cancer Surgeons

An official position statement on screening mammography from the American Society of Breast Surgeons (ASBrS), published in Annals of Surgical Oncology, called for a formal breast cancer risk assessment for all women between the ages of 25 and 30, and provides recommendations for screening mammography based on breast cancer risk.¹

Although the association between screening mammography and reduced breast cancer mortality has been supported by the findings of numerous randomized clinical trials, most of these studies were initiated 2 or more decades in the past.^1,2 Furthermore, subsequent technological advances in mammographic imaging, as well as the results of more recent investigations of the underlying biology of breast cancer, have raised questions related to the relevance of recommendations for breast cancer screening based on the earlier studies.  In particular, concerns exist regarding whether the ratio of the risks of “overdiagnosing” more indolent breast lesions compared with the outcome benefits of detecting breast cancer at an early stage has been altered. In addition, the increasing racial/ethnic diversity of the US population, as well as healthcare disparities identified in population-based subgroups, have prompted the ASBrS to re-examine current recommendations for breast cancer screening in the United States.

Differences exist between current screening mammography recommendations from the US Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS). For example, the USPSTF recommends that women at average risk undergo biennial screening mammography starting at age 50 and ending at age 75. For women between the ages of 45 and 49, the USPSTF recommends individualized decisions regarding screening mammography.³ In contrast, current ACS guidelines recommend that women at average risk of breast cancer undergo yearly mammography from age 45 to 54, with biennial (or annual screening) for women aged 55 years and older; continuation of screening is recommended as long as the woman has an estimated life expectancy of at least 10 years.⁴ However, for women aged 40 to 44 years, the ACS guidelines, like the USPSTF recommendations, include the option of screening mammography.

“The ‘shared decision-making’ approach recommended for women in their 40s has left many women and their health care providers without clarity regarding integration of screening mammography into health maintenance routines,” commented the authors of the ASBrS position statement.

The issues surrounding breast cancer screening become further complicated when considering women whose risk of breast cancer is higher than average. For example, the American College of Radiology (ACR) and the Society for Breast Imaging (SBI) guidelines recommend screening mammography starting at age 40 for women at average risk of breast cancer, and include suggestions for initiating screening at a younger age for those at higher risk (eg, women with a genetic mutation predisposing them to breast cancer, those who received prior chest or mantle radiation therapy at a young age, and some women with a personal history of breast cancer), with supplemental breast imaging (eg, contrast-enhanced breast magnetic resonance imaging [breast MRI]) recommended for some of these subgroups.⁵ Also recommended by the ACR/SBI is an assessment of breast cancer risk for all women, but especially for black women and women of Ashkenazi-Jewish descent, by age 30 years.

Highlights of the recently released guidelines from the ASBrS include the following recommendations for breast cancer risk assessment, as well as breast screening imaging, in women:¹

• All women ages 25 to 30 An assessment of breast cancer risk including family history of cancer, personal history of atypical hyperplasia or lobular carcinoma in situ (LCIS), and history of chest or mantle radiation therapy, performed by a breast physician or other qualified healthcare provider.
• Initial risk assessment at age older than 30 years An assessment of risk factors as described for women 25 to 30 years of age, as well as additional risk assessment using a validated model, with risk assessment updates at regular intervals.
• Average risk of breast cancer Initiation of yearly screening mammography (3-dimensional [3D] preferred) at age 40 years with consideration of supplemental imaging for those with dense breasts.
• Higher-than-average risk due to a pathogenic genetic alteration, or history of chest wall radiation between ages 10 and 30 years Annual screening with breast MRI starting at age 25 years with annual screening mammography (3D preferred) starting at age 30 years.
• Higher-than-average risk with a lifetime risk greater than 20% or strong family history Breast cancer screening with annual mammography (3D preferred) starting at age 35 years, with access to supplemental imaging (MRI preferred) if recommended by their physician
• Personal history of breast cancer in women who did not undergo bilateral mastectomy Annual mammography (3D preferred) with access to supplemental imaging for those with dense breast tissue or who were younger than 50 years at diagnosis, if recommended by their physician
• Older women Continuation of annual screening mammography until life expectancy is less than 10 years

In conclusion, the authors of the ASBrS position statement stated that “these screening recommendations for the overall diverse population of adult women represent an opportunity to minimize breast cancer disparities through earlier detection of disease in all women.”¹

References

1. ASBrS releases position statement on screening mammography [news release]. The American Society of Breast Surgeons website; May 3, 2019. https://www.breastsurgeons.org/news/?id=23. Accessed May 3, 2019.
2. Independent UK Panel on Breast Cancer Screening. The benefits and harms of breast cancer screening: an independent review. Lancet. 2012;380(9855):1778-1786.
3. Mandelblatt JS, Stout NK, Schechter CB, et al. Collaborative modeling of the benefits and harms associated with different U.S. breast cancer screening strategies. Ann Intern Med. 2016;164(4):215-225.
4. Oeffinger KC, Fontham ETH, Etzioni R, et al. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 2015;314(15):1599-1614.
5. Monticciolo DL, Newell MS, Moy L et al. Breast cancer screening in women at higher-than-average risk: recommendations from the ACR. J Am Coll Radiol. 2018;15(3 Pt A):408-414.

This article originally appeared on Oncology Nurse Advisor