Study: Breast cancer screening should be tailored to a woman’s risk factors and breast density
Summary
The United States Preventative Services Task Force (USPSTF) recommends a screening mammogram every other year for women ages 50-74 who are at average risk for breast cancer. But do all patients in this category benefit from this screening regimen? 10/18/16
Relevance
This article is most relevant for Women who are at high risk for breast cancer due to family history, dense breasts, LCIS, or multiple biopsies
Relevance: Medium
Strength of Science: Medium
Media Ratings
Who covered this study?
Reuters
Also published in:
The same article was also covered by
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
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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:
- 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 every two years.
- The model predicts that approximately 150 false-positive 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 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 to save one life.
- 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 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 , benign biopsies) than women at average risk who get 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.
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
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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:
- 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 every two years.
- The model predicts that approximately 150 false-positive 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 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 to save one life.
- 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 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 , benign biopsies) than women at average risk who get 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 (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.
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 benefit young women and women with dense breasts.
- (3D ) 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
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 exams 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 exams to find high-risk women who may need additional screening
- yearly –consider a , if available.
- The NCCN has a different set of guidelines for individuals who are 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 starting age and frequency of screenings.
It is important to note, that all of the groups support the opportunity for women ages 40 to 49 to decide whether screening is right for them.
Updated: 02/05/2022
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 review your personal and family history of cancer and help you to determine the best risk management plan. Note that our use of "men" and "women" refers to the sex you were assigned at birth.
Recommended screening for women with mutations:
- Beginning at age 18, be aware of how your breasts normally look and feel. Tell your doctor about any breast changes.
- Beginning at age 25, have a doctor examine your breasts every 6-12 months.
- Beginning at age 25, have an annual breast with contrast (or if is unavailable).
- Beginning at age 30 and continuing until age 75, have an annual and an annual breast with contrast.
- After age 75, speak with your doctor about the benefits and risks of screening.
Risk reduction for women:
- Speak with your doctor about the advantages and disadvantages of risk-reducing mastectomy.
- Research shows that risk-reducing mastectomy can lower the chance of developing breast cancer in high-risk women by about 90 percent. Mastectomy has not been shown to help high-risk women live longer.
- Because some breast tissue remains after mastectomy, some breast cancer risk also remains.
- Speak with your doctor about the benefits and risks of tamoxifen or other estrogen-blocking drugs to reduce your breast cancer risk. The benefits and risks may be different for women with or mutations. Research on the benefit of these drugs to reduce breast cancer risk in women with mutations has been mixed.
Risk management for men:
- Beginning at age 35, learn how to do breast self-exams to check for breast changes.
- Beginning at age 35, have a doctor examine your chest every 12 months.
- Beginning at age 50, consider an annual (especially for men with mutations).
Updated: 06/21/2024
Expert Guidelines
Laws and guidelines address screening of women with dense breasts. Laws regarding 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 identified by a should be counseled on the risks and benefits of additional breast screening.
- Digital benefit young women and women with dense breasts.
- (3D ) 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 callbacks and biopsies of benign (noncancerous) tissue.
Updated: 02/06/2022
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 determine the best risk management plan.
or
- Beginning at age 40 (or earlier based on your family history of breast cancer)
- recommend yearly
- Beginning at age 30-35
- consider yearly with and without contrast
, or
- Beginning at age 40 (or earlier based on family history):
- recommend yearly
- consider yearly breast with and without contrast
- No specific breast cancer screening guidelines. Risk management should be based on your family history of cancer.
- Beginning at age 30 (or earlier based on family history):
- recommend yearly
- consider yearly breast with contrast
- discuss risk-reducing mastectomy
- Beginning at age 30 (or earlier based on family history):
- recommend yearly
- recommend yearly breast with and without contrast
- discuss risk-reducing mastectomy with your doctor
- Beginning at age 18, learn to be aware of changes in breasts.
- Beginning at age 25:
- clinical breast exam every 6-12 months beginning at age 25 or 10 years earlier than the youngest age of onset in the family
- Beginning at age 30:
- yearly and breast with contrast beginning at age 30 or earlier based on the youngest breast cancer in the family
- discuss risk-reducing mastectomy with your doctor
- After age 75
- discuss benefits and limitations of continued screening with your doctor
- Beginning at age 30:
- clinical breast examination by a health care provider every 6 months starting at age 30
- recommend yearly
- recommend yearly with and without contrast
- discuss risk-reducing mastectomy with your doctor
- Beginning at age 18, learn to be aware of changes in your breasts.
- Beginning at age 20:
- clinical breast examination by a healthcare provider every 6 months
- recommend yearly breast with and without contrast beginning at age 20 or at the age of earliest breast cancer diagnosis if there is a history of breast cancer before age 20 in family
- Beginning at age 30
- recommend yearly
- Consider risk reducing mastectomy.
- After age 75
- discuss benefits and limitations of continued screening with your doctor
Updated: 12/17/2023
Questions To Ask Your Doctor
- Do I have dense breasts?
- What is my breast cancer risk?
- Should I have genetic testing for an ?
- 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
The following breast cancer screening clinical trials are currently enrolling participants:
- NCT03220893: Comparison of Molecular Breast Imaging and Digital Breast for Screening in Women With Dense Breasts (MBI-DBT). This study will compare MBI, a relatively low-cost functional breast imaging technique, to DBT, the new standard anatomic breast cancer screening technique in women with dense breasts.
- NCT02620852: Women Informed to Screen Depending on Measures of Risk (WISDOM) study. The goal of this study is to determine if breast cancer screening can be made better by personalizing each woman’s schedule, compared to the current one-size-fits-all, annual approach.
- NCT03979729: Breast Cancer Screening for Underserved Women: Comparing Outcomes and Lowering Recall Rates With 3D- vs. 2D-mammography is recruiting participants in New Mexico who are over age 40 to improve utility among underserved women.
- NCT03482557: Contrast Enhanced Spectral vs. for Breast Cancer Screening is recruiting women 30 years or older who are already getting a breast biopsy. Participants will have a contrast-enhanced and a breast before the biopsy. Radiologists will compare the images to see if the contrast enhanced and breast are equally proficient at detecting breast cancer.
- NCT03859492: Screening CEDM in Intermediate and High-Risk Patient Populations is a clinical trial at the Mayo Clinic in Arizona that is testing whether Contrast Enhanced Digital (CEDM) can improve breast cancer detection among women age 35 years and older who have an intermediate or high risk of breast cancer.
- NCT03233191: Digital Mammography and Digital in Screening Patients for Breast Cancer. The goal of this phase III trial is to evaluate digital mammography and digital in screening patients for breast cancer.
- NCT03303846: Combined Breast and Strategies in Identifying High-risk Breast Cancer Patients trial. This clinical trial is recruiting participants age 18 and older. Study sites are in California, North Carolina, Ohio and Wisconsin.
Open Clinical Trials
The following are breast cancer screening or prevention studies enrolling people at high risk for breast cancer.
- NCT04711109: Denosumab for Preventing Breast Cancer in Women with a Inherited Mutation (BRCA-P). This study will test the effectiveness of a drug (denosumab) in preventing the development of breast cancer in women with an inherited mutation.
- NCT04067726: Denosumab and Mammographic Density in Premenopausal Women With Dense Breasts (TRIDENT). This study is looking at the drug denosumab to learn if it can reduce breast density in high-risk premenopausal women who have dense breasts.
- The Risk Factor Analysis of Hereditary Breast and Ovarian Cancer In Women with , or Mutations. This study seeks to improve researchers’ understanding of how hormonal, reproductive and lifestyle factors may be associated with cancer in high-risk people.
- NCT02620852: Women Informed to Screen Depending on Measures of Risk (WISDOM) study. The goal of this study is to determine if breast cancer screening can be improved by personalizing each woman’s schedule, compared to the current one-size-fits-all annual approach.
-
NCT04674306: Therapy With an Alpha-lactalbumin Vaccine in . This study is testing a new vaccine to lower the risk of breast cancer in high-risk women with an in , or .
Additional risk-management clinical trials for people at high risk for breast cancer may be found here.
Updated: 01/24/2024
Related Resources
The following organizations have breast cancer screening resources.
- FORCE resources:
- Information: Breast Cancer Screening
- Information: on Insurance Coverage for Breast Cancer Screening
- XRAY category: Breast Cancer Screening
- National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides low-income, uninsured and underinsured women with access to breast screenings (including MRIs for high-risk women in some states) and diagnostic services.
- American Breast Cancer Foundation’s Breast Cancer Assistance Program provides aid for breast cancer screenings and diagnostic tests for uninsured and underserved individuals, regardless of age or gender.
- The website www.densebreast-info.org offers information on breast density.
Updated: 09/27/2024
Who covered this study?
Reuters
Also published in:
The same article was also covered by
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