Study: Breast cancer screening should be tailored to a woman’s risk factors and breast density

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Contents

At a glance                  Questions for your doctor
Findings               In-depth                
Clinical trials Limitations
Guidelines Resources


STUDY AT A GLANCE

This study is about:

Using personal breast cancer risk and breast density to determine the frequency of for women over age 50.

Why is this study important?

The widespread use of screening and treatment has resulted in fewer breast cancer deaths for women in the United States. But along with the benefits, some harms come from detection and early intervention.

Study findings: 

  1. Using a computer model, researchers predict that every three years for women who are age 50 and older with average risk for breast cancer and low breast density produces similar or better benefits and harms compared to women who are at average risk and get mammograms every two years.
    • The model predicts that approximately 150 false-positive mammograms will occur to avoid one breast cancer death if women at average risk who have low breast density are screened every two years. It also predicts that with triennial screening, approximately 125 false-positive mammograms will occur to avoid one death due to breast cancer. This means that according to the model predictions, screening women at average risk every three years will lessen the number that receive false-positive mammograms to save one life.
  2. Using a computer model, researchers predict that every year for women who are age 50 and older with higher risk for breast cancer and high breast density produces similar or better benefits and harms compared to women who are at average risk and get mammograms every two years.
    • This means that annual are more beneficial for women with high breast density and high risk for breast cancer, because they have a better balance of benefits (more breast cancer deaths avoided) and harms (false-positive mammograms, benign biopsies) than women at average risk who get mammograms every two years.

What does this mean for me?

This study uses computer models to suggest that breast cancer screening intervals can be tailored to each woman depending on her breast cancer risk and breast density. Researchers did not study actual patients who had screening every one, two or three years. Instead, they modeled and predicted what would happen if these women were to use these screening intervals. More work needs to be done to understand how we can tailor screening intervals for each patient. Currently, patients and their health care providers should work together to determine a patient’s optimal breast cancer screening interval based on her personal breast cancer risk factors.

Posted 10/18/16

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References

Trentham-Dietz A, Kerlikowske K, Stout NK, et al. “Tailoring Breast Cancer Screening Intervals by Breast Density and Risk for Women Aged 50 Years or Older: Collaborative Modeling of Screening Outcomes.Annals of Internal Medicine. Published online first on August 23, 2016.  

Siu, AL and the U.S. Preventive Services Task Force. “Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement.Annals of Internal Medicine. 2016, 164(4): 279-296.

Disclosure

FORCE receives funding from industry sponsors, including companies that manufacture cancer drugs, tests and devices. All XRAYS articles are written independently of any sponsor and are reviewed by members of our Scientific Advisory Board prior to publication to assure scientific integrity.

This article is relevant for:

Women who are at high risk for breast cancer due to family history, dense breasts, LCIS, or multiple biopsies

This article is also relevant for:

Healthy people with average cancer risk

Women over 45

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Expert Guidelines Expert Guidelines

The National Comprehensive Cancer Network (NCCN) establishes guidelines for breast cancer screening and cancer care in the U.S. For women with increased risk (a lifetime risk for breast cancer of 20% or more), the guidelines recommend the following screening:

  • Have clinical exams every 6–12 months, starting when you are identified as being at increased risk, but not before age 21
  • Obtain a referral to genetic counselor or similarly trained health care provider, if you haven’t already done so.
  • Start annual screening 10 years earlier than the age of the youngest family member who has been diagnosed with breast cancer, but not prior to age 30. Consider getting a 3-D .
  • Begin annual breast 10 years earlier than the age of the youngest family member who has been diagnosed with breast cancer, but not prior to age 25.
  • Consider recommended risk reduction strategies, such as preventive hormonal medications or risk-reducing surgeries that remove the breasts or ovaries.
  • Develop breast awareness and report any changes to your health care providers

With regards to dense breasts and screening, NCCN guidelines state the following: 

  • For women with dense breasts on , women should be counseled on the risks and benefits of supplemental breast screening. 
  • Digital mammograms benefit young women and women with dense breasts.
  • (3D mammograms) can increase cancer detection and lower the chances of additional call backs.
  • Dense breasts on are associated with a higher risk for breast cancer. 
  • increases detection of cancers in women with dense breasts but also increases number of call backs and biopsies of benign (noncancerous) tissue. 

Laws on breast density notification vary by state

Expert Guidelines Expert Guidelines

The National Comprehensive Cancer Network breast screening guidelines recommend the following for women at average risk for breast cancer: 

  • ages 25-39: 
    • practice breast awareness
    • clinical breast exam every 1-3 years
    • risk assessment, including questions about family and personal medical history should be done during clinical exam to find high risk women who may need additional screening
  • ages 40 and older:
    • practice breast awareness
    • yearly clinical breast exam
    • risk assessment, including questions about family and personal medical history should be done during clinical exam to find high risk women who may need additional screening
    • yearly  - consider 3D mammograms if available. 
  • NCCN has a different set of guidelines for individuals who are determined to be at increased risk for breast cancer.

Many other professional societies and organizations have breast cancer screening guidelines that differ slightly. They don't all agree on the age screening should start and how frequently they should be done. 

It is important to note, that all the groups support the opportunity for women ages 40 to 49 to decide it screening is right for them.

Updated: 02/05/2022

Expert Guidelines Expert Guidelines

There are laws and guidelines for screening in women with dense breasts. The laws on breast density notification vary by state. The National Comprehensive Cancer Network (NCCN) has guidelines on breast screening. The panel notes that dense breasts are associated with an increased risk for breast cancer, and they recommend the following: 

  • Women with dense breasts on  should be counseled on the risks and benefits of additional breast screening. 
  • Digital mammograms benefit young women and women with dense breasts.
  • (3D mammograms) can increase cancer detection and lower the chances of additional call backs.
  • may improve the detection of cancers in women with dense breasts but it can also increase the number of call backs and biopsies of benign (noncancerous) tissue. 

Updated: 02/06/2022

Expert Guidelines Expert Guidelines

The National Comprehensive Cancer Network (NCCN) provides breast cancer risk management guidelines for people with and mutations. We recommend that you speak with a genetics expert who can look at your personal and family history of cancer and can help you to determine the best risk management plan. 

Screening for women:

  • Learn to be aware of changes in breasts beginning at age 18.
  • Clinical breast exam every 6-12 months beginning at age 25.
  • Annual breast  with contrast (or  if  is unavailable) beginning at age 25 and continuing until age 75.
  • Annual  at age 30 until age 75 (consider 3D  if available).
  • Screening after age 75 should be considered on an individual basis.

Risk reduction for women:

  • Women should have a discussion with their doctors about of the advantages and disadvantages of risk-reducing mastectomy.
    • Research has shown that risk-reducing mastectomy can lower the risk for breast cancer in high risk women by about 90%. Despite this, mastectomy has not been shown to help high risk women live longer.
    • Even after mastectomies, some breast tissue-and therefore some breast cancer risk remains. 
  • Women should have a conversation with their doctor about the possible benefits of tamoxifen or other estrogen-blocking drugs to reduce breast cancer risk in women with  mutations. Research on the benefit of these drugs to reduce breast cancer risk in women with  mutations has been mixed.

Risk management in men:

  • Breast self-exam training and education beginning at age 35.
  • Clinical breast exam every 12 months beginning at age 35.
  • In men with enlarged breasts, (gynecomastia) consider annual  in men with gynecomastia beginning at age 50 or 10 years younger then the earliest case of male breast cancer in the family (whichever comes first). 

Updated: 12/14/2021

Expert Guidelines Expert Guidelines

The National Comprehensive Cancer Network (NCCN) provides guidelines for management of breast cancer risk in people with inherited mutations linked to breast cancer. We recommend that you speak with a genetics expert who can look at your personal and family history of cancer and help you to determine the best risk management plan. 

 or

  • Beginning at age 40 (or earlier based on family history):
    • recommend annual  (consider 3D , if available).
    • consider annual breast  with contrast.

, or

  • No specific breast cancer screening guidelines. Risk management should be based on family history of cancer.

 

  • Beginning at age 30 (or earlier based on family history):
    • recommend annual  (consider 3D , if available).
    • consider annual breast  with contrast.
    • discuss risk reducing mastectomy. 

  • Beginning at age 30 (or earlier based on family history):
    • recommend annual  (consider 3D , if available).
    • recommend annual breast  with contrast.
    • discuss risk reducing mastectomy. 

  • Be aware of endometrial cancer symptoms.
  • Consider endometrial biopsy every 1-2 years beginning at age 35.
  • For post-menopausal women, consider transvaginal after discussion with your doctor. 
  • Consider risk-reducing hysterectomy. 

  • Clinical breast examination by a health care provider twice a year starting at age 30.
  • Recommend annual .
  • Recommend annual .

  • Breast self-awareness beginning at age 18.
  • Clinical breast examination by a health care provider twice a year starting by age 20.
  • Annual breast  with contrast beginning at age 20 (or  if  not available, but  is preferred) or at the age of earliest breast cancer diagnosis if there is a history of breast cancer before age 20 in family.
  • Annual breast  and  beginning at age 30 (consider 3D ). 
  • Consider risk reducing mastectomy.

Updated: 03/19/2022

Questions to Ask Questions to Ask Your Doctor

  • Do I have dense breasts?
  • What is my breast cancer risk?
  • Should I have genetic testing for an inherited mutation?
  • Can you refer me to a genetic counselor?
  • How can I lower my breast cancer risk?
  • When should I start breast cancer screening?
  • I have a family history of breast cancer; should I start before age 50?
  • I have a mutation in a gene associated with increased breast cancer risk; what other breast screening should I consider?
  • I received a dense breast notification at my last mammogram; what type of breast cancer screening do I need?

Open Clinical Trials Open Clinical Trials

The following breast cancer screening clinical trials are currently enrolling participants:

Open Clinical Trials Open Clinical Trials

The following are breast cancer screening or prevention studies enrolling people at high risk for breast cancer.   

Additional risk-management clinical trials for people at high risk for breast cancer may be found here.

Updated: 03/19/2022

Who covered this study?

Reuters

Also published in:

The same article was also covered by

Fox News

Yahoo News

Women with dense breasts may need annual mammograms This article rates 4.0 out of 5 stars

ABC News

Breast density matters for cancer screening, study finds This article rates 3.5 out of 5 stars

Medical Xpress

Breast density and risk may be useful for guiding mammography screening frequency This article rates 3.0 out of 5 stars

Cancer Therapy Advisor

Breast density and risk factors indicate breast cancer screening intervals This article rates 2.5 out of 5 stars

How we rated the media

IN DEPTH REVIEW OF RESEARCH

Study background:

The 2016 U.S. Preventive Services Task Force () made the controversial recommendation that women aged 50-74 should get every other year, rather than annually. However, do all women in this age group benefit from the same regime? Amy Trentham-Dietz and her colleagues from the University of Wisconsin Carbone Cancer Center and other institutions published work in the Annals of Internal Medicine that addresses this question.

Researchers of this study wanted to know:

Can a woman’s breast density and breast cancer risk be used to determine the optimal time between her ?

Population(s) looked at in the study:

Researchers from the Cancer Intervention and Surveillance Modeling Network and the Breast Cancer Surveillance Consortium used three well-established models (Models E, GE, and W) to predict the benefits and harms of for women 50 years and older with various combinations of breast cancer risk and breast densities. This model used data collected from 1975-2010 by the Surveillance, Epidemiology, and End Results () program. The women modeled were at average or moderate (not greater than four times increased risk) risk for breast cancer. Factors leading to a moderate risk of breast cancer included postmenopausal obesity, a history of benign breast biopsies, and a history of lobular carcinoma in situ ().  Note that moderate breast cancer risk is not as great as the risk of women with mutations.  Benefits measured were breast cancer deaths avoided due to screening, and quality-adjusted life-years. Harmful outcomes measured were mammograms, benign biopsies, and (defined as “ cancer that would not have been diagnosed in a woman's lifetime in the absence of ”).

Study findings: 

  1. Using a computer model, researchers predict that every three years for women who are age 50 and older with average risk for breast cancer and low breast density produces similar or better benefits and harms compared to women who are at average risk and get mammograms every two years.
    • The model predicts that approximately 150 false-positive mammograms will occur to avoid one breast cancer death if women at average risk who have low breast density are screened every two years. It also predicts that with triennial screening, approximately 125 false-positive mammograms will occur to avoid one death due to breast cancer. This means that according to the model predictions, screening women at average risk every three years will lessen the number that receive false-positive mammograms to save one life.
  2. Using a computer model, researchers predict that every year for women who are age 50 and older with higher risk for breast cancer and high breast density produces similar or better benefits and harms compared to women who are at average risk and get mammograms every two years.
    • This means that annual are more beneficial for women with high breast density and high risk for breast cancer, because they have a better balance of benefits (more breast cancer deaths avoided) and harms (false-positive mammograms, benign biopsies) than women at average risk who get mammograms every two years.

Limitations:

Because this study only included information from women who were 50 years and older, the findings do not apply to younger women. Nor did it look at women who are at higher risk of breast cancer due to a genetic mutation such as that increases breast cancer risk. And finally, because these results are predicted from a computer model, it assumes that patients will adhere to the screening schedule, which may not be the case for all women.  

The conclusions also hinge on how the authors define harm and whether patients would use the same definition. For some women, being called back for additional screening or having a benign biopsy may appear to be a harm.  Other women may prefer to have this additional screening, despite the risk that a detected abnormality turns out to be something other than cancer. This points to a need for personalizing breast screening, not only based on a patient’s risk for breast cancer, but also on her preferences.

It is important to note that this paper used current guidelines for breast cancer screening in average risk women as a starting point. These guidelines are controversial and differ from others. Guidelines of numerous other organizations, including the American Cancer Society (ACS), the National Comprehensive Cancer Network (NCCN), the American Medical Association (AMA), the American College of Radiology (ACR), and the American Congress of Obstetricians and Gynecologists (ACOG) recommend annual beginning at younger ages—the ACS recommends age 45, while the other organizations recommend age 40. Recently, the NCCN added that women and their doctors consider using 3D (), which is not addressed in this study. 

Separate guidelines exist for women known to be at high risk for breast cancer due to mutations in or other genes associated with increased cancer risk, a strong family history of breast cancer, and/or history of radiation treatment to the chest. In some cases, guidelines recommend combining magnetic resonance imaging () with . These types of screening were not addressed by this study.

Conclusions:

This study suggests that a woman’s breast density and breast cancer risk can be used to tailor her breast cancer screening interval. These findings are not definitive, because they used computer models to predict the results of being screened at one-, two-, or three-year intervals. However, this research opens discussion on how to tailor screening to benefit each patient individually. Additionally, more work needs to be done to address the limitations of the study, including women who are younger and have mutations in genes that increase cancer risk.

While this study is a step towards personalizing breast cancer screening for women who do not have mutations in or other genes that increase cancer risk, more work is needed to correctly identify women who would benefit from increased screening. Patients and their health care providers should work together to determine a patients’ optimal screening regimen based on personal and family history of cancer, as well as the patient’s tolerance for the risk of false positives and/or benign biopsies.     

Posted 10/18/16

Share your thoughts on this XRAYS article by taking our brief survey.

References

Trentham-Dietz A, Kerlikowske K, Stout NK, et al. “Tailoring Breast Cancer Screening Intervals by Breast Density and Risk for Women Aged 50 Years or Older: Collaborative Modeling of Screening Outcomes.Annals of Internal Medicine. Published online first on August 23, 2016.  

Siu, AL and the U.S. Preventive Services Task Force. “Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement.Annals of Internal Medicine. 2016, 164(4): 279-296.

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