The standard screening modalities of mammography and physical examination are complementary. Approximately 10% to 50% of cancers detected mammographically are not palpable, whereas physical examination detects 10% to 20% of cancers not seen radiographically (17). The purpose of screening is to detect tumors when they are small (<1 cm) and have the highest potential for surgical cure. Most trials show a 20% to 30% reduction in breast cancer mortality for women age 50 and older who undergo annual screening mammography. Data on screening women younger than 40 years are more controversial. Results from the Gothenburg screening trial showed a 45% reduction in mortality for women screened between the ages of 40 and 49 (18). Because of these findings, it is recommended that all women undergo yearly screening mammography starting at age 40, along with clinical breast examination at least every 3 years (19). Monthly breast self-examination (BSE) is no longer recommended because there is little evidence to show that BSE is superior to heightened breast awareness such that any new symptoms related to the breast in daily activities would be reported promptly when noticed. BSE was not shown to improve survival. Women should be informed about the benefits and limitations of monthly BSE, mainly the risk of a false-positive result. Women who would still prefer to perform BSE should be instructed in the technique and occasionally have their technique reviewed. No other tests, including ultrasonography, computed tomography (CT) scans, sestamibi scans, positron emission tomography (PET) scans, or serum blood markers, have been shown to be effective screening modalities. Screening guidelines recommended by the American College of Radiology and the American Cancer Society are presented in Table 40.1. In 2010, the ACS recommended annual screening mammography and magnetic resonance imaging (MRI) starting at age 30 for women with a known BRCA mutation and other high-risk genetic syndromes, women who are untested with a first-degree relative with the BRCA mutation and women with an approximately 20% to 25% or greater lifetime risk of breast cancer, or women who have been treated with radiation for Hodgkin’s lymphoma (19). Although breast MRI may prove to be advantageous for other women with an elevated risk of breast cancer, there
Table 40.1 Screening Recommendations
Beginning at age 40 yearly mammograms, which should continue as long as the patient is in good health.
Is an option for women starting in their 20s. Women should be counseled on the benefits and limitation of breast self-examination and should be told to report any changes in their breasts to their health professional right away.
Age 20–40 examination by physician every 3 years, annually if positive history (May do annually if there is a positive family history) Age ≥ 40 examination by physician every year
Medium risk women (15%–20% lifetime risk) should talk to their health care professional about the benefits and limitations of adding MRI to their yearly mammographic screening.
Low risk women (less than 15% lifetime risk) are not recommended to undergo additional MRI screening.
From American Cancer Society Screening Guidelines. Smith RA, Cokkinides V, Brooks D, et al. Cancer screening in the United States, 2010: a review of current American Cancer Society Guidelines and Issues in Cancer Screening. CA Cancer J Clin 2010;60:99–119.
is currently insufficient evidence to make recommendations for women with lower than a 20% lifetime risk of breast cancer (19).
Masses are easier to palpate in older women with fatty breasts than in younger women with dense, nodular breasts. An area of thickening amid normal nodularity may be the only clue to an underlying malignancy. Skin dimpling, nipple retraction, or skin erosion, while obvious, are later-stage disease signs. Algorithms for the evaluation of breast masses in premenopausal and postmenopausal women are presented in Chapter 21.