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Breast Cancer Screening Breast Cancer Screening1 Page 1 of 6 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. Note: This algorithm is not intended for women with a personal history of breast cancer2. Breast cancer screening may continue as long as a woman has a 10-year life expectancy and no co-morbidities that would limit the diagnostic evaluation or treatment of any identified problem. Women should be counseled about the benefits, risks and limitations of screening mammography. RISK AGE TO BEGIN SCREENING SCREENING 4 ● Consider clinical breast exam every 1-3 years Age 25 - 39 years 5 ● Breast awareness Average 3 ● Annual clinical breast exam risk 6 ● Annual screening mammogram Age ≥ 40 years 7 ○ Consider tomosynthesis 5 ● Breast awareness ● Annual clinical breast exam (begin 8-10 years after radiation therapy) Age ≤ 24 years 5 ● Breast awareness Prior thoracic radiation therapy ● Clinical breast exam every 6-12 months (begin 8-10 years after radiation therapy) at ages 10-30 years 6 ● Annual screening mammogram (begin 8-10 years after radiation therapy but not prior to age 25 years) 7 Age ≥ 25 years ○ Consider tomosynthesis 8,9 ● Recommend annual MRI Increased (begin 8-10 years after radiation therapy but not prior to age 25 years) risk 5 ● Breast awareness ● Clinical breast exam every 6-12 months (begin at age identified as being at increased risk) 6 ● Annual screening mammogram (begin at age identified as being at increased risk) 5-year risk of invasive breast cancer by Gail model calculation 7 ○ Consider tomosynthesis ≥ 1.7% in women > 35 years old ● Consider risk reduction strategies (see Breast Cancer Risk Reduction Therapy algorithm) 5 ● Breast awareness 10 ● Women who have a lifetime risk ≥ 20% as defined by models that are dependent on family history ● Genetic predisposition (see Appendix A) ● Lobular Carcinoma In Situ (LCIS) See Page 2 ● Atypical Ductal Hyperplasia (ADH)/Atypical Lobular Hyperplasia (ALH) 1 For transgender patients, recommend performing a breast cancer risk assessment and making 7 Tomosynthesis improves cancer detection and decreases recall rates individualized screening recommendations 8 Risk of breast cancer begins to increase 8-10 years after thoracic exposure. The optimal age to begin MRI screening in this high risk 2 See the Breast Cancer Treatment or Survivorship algorithms for the management of women with a population is not currently known. personal history of breast cancer 9 Current practice at MD Anderson is to alternate the mammogram and breast MRI every 6 months. While there is no data to suggest 3 Patients who do not meet one of the increased risk categories that this is the optimal approach, it is done with the expectation that interval cancers may be identified earlier. Other screening 4 Effectiveness of clinical breast exams has not been assessed in patients 25-39 years of age regimens, such as breast MRI performed at the time of the annual mammogram, are also acceptable. 5 Patients should be familiar with their breasts and promptly report changes to their healthcare provider 10 Risk models that are largely dependent on family history include Tyrer-Cuzick and Claus 6 Augmented breasts need additional views for complete assessment Department of Clinical Effectiveness V8 Approved by The Executive Committee of Medical Staff on 11/17/2020 Breast Cancer Screening1 Page 2 of 6 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. Note: This algorithm is not intended for women with a personal history of breast cancer1. Breast cancer screening may continue as long as a woman has a 10-year life expectancy and no co-morbidities that would limit the diagnostic evaluation or treatment of any identified problem. Women should be counseled about the benefits, risks and limitations of screening mammography. RISK AGE TO BEGIN SCREENING SCREENING ● Clinical breast exam every 6-12 months A (begin at age identified as being at increased risk; refer to genetic counselor, if not already done) 3 ● Annual screening mammogram Women who have a lifetime risk (begin 10 years before youngest case in the family but not prior to age 30 years) ≥ 20% as defined by models that 4 ○ Consider tomosynthesis 2 5 are dependent on family history ● Recommend MRI (begin 10 years before youngest family member but not prior to age 25 years) ● Consider risk reduction strategies (see Breast Cancer Risk Reduction Therapy algorithm) 6 ● Breast awareness ● Annual clinical breast exam Age ≤ 24 years 6 Increased ● Breast awareness BRCA 1 or BRCA 2 genetic risk ● Clinical breast exam every 6-12 months (begin at the age identified as being at increased risk) predisposition (for other 3 ● Annual screening mammogram predispositions see Appendix A) (begin 10 years before youngest case in the family but not prior to age 30 years) 4 ○ Consider tomosynthesis Age ≥ 25 years 5 ● Recommend annual MRI (begin 10 years before youngest case in the family but not prior to age 25 years) ● Consider risk reduction strategies (see Breast Cancer Risk Reduction Therapy algorithm) 6 ● Breast awareness ● Clinical breast exam every 6-12 months (begin at diagnosis of LCIS or ADH/ALH) 3 ● Annual screening mammogram (begin at diagnosis of LCIS or ADH/ALH but not prior to age 30 years) Women who have a lifetime risk ≥ 20% 4 ○ Consider tomosynthesis based on: 5,7 ● Consider annual MRI based on emerging data ● LCIS (begin at diagnosis of LCIS or ADH/ALH but not prior to age 25 years) ● ADH/ALH ● Begin risk reduction strategies (see Breast Cancer Risk Reduction Therapy algorithm) (begin at diagnosis of LCIS or ADH/ALH but not prior to age 35 years) 6 ● Breast awareness 1 See the Breast Cancer Treatment or Survivorship algorithms for the management of women with a 5 Current practice at MD Anderson is to alternate the mammogram and breast MRI every 6 months. While there is no data to suggest personal history of breast cancer that this is the optimal approach, it is done with the expectation that interval cancers may be identified earlier. Other screening 2 Risk models that are largely dependent on family history include Tyrer-Cuzick and Claus regimens, such as breast MRI performed at the time of the annual mammogram, are also acceptable. 3 Augmented breasts need additional views for complete assessment 6 Patients should be familiar with their breasts and promptly report changes to their healthcare provider 4 Tomosynthesis improves cancer detection and decreases recall rates 7 Patient should be educated that insurance may not cover the MRI Department of Clinical Effectiveness V8 Approved by The Executive Committee of Medical Staff on 11/17/2020 Breast Cancer Screening1 Page 3 of 6 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. APPENDIX A: Breast Management based on Genetic Test Results1,2 Increased risk of breast cancer 3,4 ATM ● Screening: annual mammogram with consideration of tomosynthesis and consider breast MRI with contrast starting at age 40 years ● RRM: evidence insufficient, manage based on family history BARD1 Potential increase in breast cancer risk, with insufficient evidence for management recommendations BRIP1 Unknown or insufficient evidence Increased risk of lobular breast cancer 3,4 CDH1 ● Screening: annual mammogram with consideration of tomosynthesis and consider breast MRI with contrast starting at age 30 years ● RRM: evidence insufficient, manage based on family history Increased risk of breast cancer 3,4 CHEK2 ● Screening: annual mammogram with consideration of tomosynthesis and consider breast MRI with contrast starting at age 40 years ● RRM: evidence insufficient, manage based on family history MSH2, MLH1, 4 MSH6, PMS2, Unknown or insufficient evidence for breast cancer risk EPCAM ● Manage based on family history, as per Box A on Page 2 Increased risk of breast cancer 3,4 NBN ● Screening: annual mammogram with consideration of tomosynthesis and consider breast MRI with contrast starting at age 40 years ● RRM: evidence insufficient, manage based on family history Increased risk of breast cancer ● Screening: annual mammogram with consideration of tomosynthesis starting at age 30 years and consider breast MRI with contrast from NF1 3,4 ages 30-50 years ● RRM: evidence insufficient, manage based on family history RRM = risk-reducing mastectomy 1
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