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Practice Bulletin No. 179 Summary: Breast Cancer Risk Assessment and Screening in Average-Risk Women

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doi: 10.1097/AOG.0000000000002151
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Clinical Management Questions

  • How should individual breast cancer risk be assessed?
  • Is screening breast self-examination recommended in women at average risk of breast cancer, and what should women do if they notice a change in one of their breasts?
  • Should practitioners perform routine screening clinical breast examinations in average-risk women?
  • When should screening mammography begin in average-risk women?
  • How frequently should screening mammography be performed in average-risk women?
  • When should screening mammography cease?

Summary of Recommendations

Recommendations based on good and consistent scientific evidence (Level A)

  • Women at average risk of breast cancer should be offered screening mammography starting at age 40 years. Women at average risk of breast cancer should initiate screening mammography no earlier than age 40 years. If they have not initiated screening in their 40s, they should begin screening mammography by no later than age 50 years. The decision about the age to begin mammography screening should be made through a shared decision-making process. This discussion should include information about the potential benefits and harms.
  • Women at average risk of breast cancer should have screening mammography every 1 or 2 years based on an informed, shared decision-making process that includes a discussion of the benefits and harms of annual and biennial screening and incorporates patient values and preferences. Biennial screening mammography, particularly after age 55 years, is a reasonable option to reduce the frequency of harms, as long as patient counseling includes a discussion that with decreased screening comes some reduction in benefits.
  • Women at average risk of breast cancer should continue screening mammography until at least age 75 years.

Recommendations based on limited or inconsistent scientific evidence (Level B)

  • Health care providers periodically should assess breast cancer risk by reviewing the patient’s history.
  • Women with a potentially increased risk of breast cancer based on initial history should have further risk assessment.
  • Breast self-examination is not recommended in average-risk women because there is a risk of harm from false-positive test results and a lack of evidence of benefit.

Recommendations based primarily on consensus and expert opinion (Level C)

  • Screening clinical breast examination may be offered to asymptomatic, average-risk women in the context of an informed, shared decision-making approach that recognizes the uncertainty of additional benefits and the possibility of adverse consequences of clinical breast examination beyond screening mammography. If performed for screening, intervals of every 1–3 years for women aged 25–39 years and annually for women aged 40 years and older are reasonable. The clinical breast examination continues to be a recommended part of evaluation of high-risk women and women with symptoms.
  • Average-risk women should be counseled about breast self-awareness and encouraged to notify their health care provider if they experience a change. Breast self-awareness is defined as a woman’s awareness of the normal appearance and feel of her breasts.
  • Age alone should not be the basis to continue or discontinue screening. Beyond age 75 years, the decision to discontinue screening mammography should be based on a shared decision making process informed by the woman’s health status and longevity.

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force. Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A—Recommendations are based on good and consistent scientific evidence.

Level B—Recommendations are based on limited or inconsistent scientific evidence.

Level C—Recommendations are based primarily on consensus and expert opinion.

© 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.