Screening for breast cancer

Abstract

Context: Breast cancer screening in community practices may be different from that in randomized controlled trials. New screening modalities are becoming available.

Objectives: To review breast cancer screening, especially in the community and to examine evidence about new screening modalities.

Data sources and study selection: English-language articles of randomized controlled trials assessing effectiveness of breast cancer screening were reviewed, as well as meta-analyses, systematic reviews, studies of breast cancer screening in the community, and guidelines. Also, studies of newer screening modalities were assessed.

Data synthesis: All major US medical organizations recommend screening mammography for women aged 40 years and older. Screening mammography reduces breast cancer mortality by about 20% to 35% in women aged 50 to 69 years and slightly less in women aged 40 to 49 years at 14 years of follow-up. Approximately 95% of women with abnormalities on screening mammograms do not have breast cancer with variability based on such factors as age of the woman and assessment category assigned by the radiologist. Studies comparing full-field digital mammography to screen film have not shown statistically significant differences in cancer detection while the impact on recall rates (percentage of screening mammograms considered to have positive results) was unclear. One study suggested that computer-aided detection increases cancer detection rates and recall rates while a second larger study did not find any significant differences. Screening clinical breast examination detects some cancers missed by mammography, but the sensitivity reported in the community is lower (28% to 36%) than in randomized trials (about 54%). Breast self-examination has not been shown to be effective in reducing breast cancer mortality, but it does increase the number of breast biopsies performed because of false-positives. Magnetic resonance imaging and ultrasound are being studied for screening women at high risk for breast cancer but are not recommended for screening the general population. Sensitivity of magnetic resonance imaging in high-risk women has been found to be much higher than that of mammography but specificity is generally lower. Effect of the magnetic resonance imaging on breast cancer mortality is not known. A balanced discussion of possible benefits and harms of screening should be undertaken with each woman.

Conclusions: In the community, mammography remains the main screening tool while the effectiveness of clinical breast examination and self-examination are less. New screening modalities are unlikely to replace mammography in the near future for screening the general population.

Figures

Figure 1. Computer-Aided Detection Markers of Breast Imaging Screening Mammography

Examination with subtle focal asymmetric density on mammography examination of the right breast, mediolateral oblique view. The density is marked by the computer-aided detection program, with a star to call attention to a possible cancer. Breast biopsy confirmed infiltrating ductal carcinoma. The triangle notes calcification in the same breast.

Figure 2. Magnetic Resonance Imaging Examination of the Breast

A 35-year-old woman at increased risk for breast cancer based on a strong family history of breast cancer obtained screening magnetic resonance imagery examination, before, A, and after contrast injection, B. Examination revealed a 1.3 cm mass in her left breast (arrowhead), occult on screening mammography examinations. Biopsy confirmed infiltrating ductal carcinoma. (See also http://depts.washington.edu/gim/faculty/elmore.htm for example of 3-dimensional rotation of magnetic resonance imagery views.)