Guidelines for Screening Mammography

Monica Rocco, MD, Breast Surgical Oncology

Controversy surrounding screening mammography guidelines has resulted in conflicting recommendations from physicians and uncertainty for women. Because the technology of mammography imaging and has progressed substantially, and we have a deeper understanding of the complexity of the breast tumor biology, there are concerns regarding the balance between “over-diagnosis” versus the outcome benefits of early detection.

The following guidelines are put forth by the American Society of Breast Surgeon and make clear recommendations regarding breast cancer screening for both women with average and higher risk, as well as make surveillance imaging recommendations for women with a prior history of breast cancer.
To determine the appropriate screening approach, the first step is risk assessment. All women should undergo a risk assessment starting between the ages of 25-30 and update at appropriate intervals. Women with an average risk of breast cancer should initiate yearly screening 3D mammograms at age 40.There is currently no data to support routine screening of women under age 40 who have average risk. Additionally, if the women with average risk have non-dense breasts (density A/B), then there is no need for additional imaging. However, if the women with average risk have increased density (density C/D), then supplemental imaging considered. Women should discuss their imaging results with their physicians and decide which supplemental imaging is appropriate, ultrasound versus MRI.

Women with a higher than average risk of breast cancer can be divided into two groups. First, women who have increased risk, due to a pathogenic mutation or history of prior chest wall radiation between the ages 10-30. These high risk women should have an annual bilateral breast MRI at age 25 and an annual 3D mammography starting at age 30. The second group of women has a lifetime risk of greater than 20% determined by any risk model (TyrerCusick preferred) or a strong family history. These women should have an annual 3D mammography and access to supplemental imaging (MRI preferred) starting at age 35 when recommended by their physician.
Women with prior history of breast cancer older than or equal to age 50 with non-dense breasts (density A/B) and have NOT had mastectomy, should have an annual 3D mammography.

Women with prior history of breast cancer at less than 50 years of age or with dense breasts (density C/D), should have an annual 3D mammography and access to annual supplement imaging with breast MRI being the preferred modality when recommended by their physician.
Women can stop mammography screening when the life expectancy is less than 10 years.

There has always been a debate as to whether there is any true benefit to screening mammograms for women age 40-49. There is heightened relevance in discussions of breast cancer disparities related to racial-ethnic identity. A comprehensive review of the multifactorial etiology of this important issue and its impact on the full spectrum of our diverse American population showed a few well-documented differences in the breast cancer burden of African American compared to white American women. The age distribution of breast cancer is younger, and the stage distribution is more advanced in African American women. Population based
breast cancer mortality rates are higher among African American women, and population based incidence rates of triple-negative (estrogen negative, progesterone negative,Her2neunegative) breast cancer are two-fold higher among African American women. Although the extent to which mammogram screenings can reverse outcome disparities is unclear, the benefits of early detection through screening for all breast tumor phenotypes (improved survival, reduced need for chemotherapy) are compelling arguments in favor of mammography screening as a valuable weapon in achieving health equity.

Talk to your doctor about your screening needs. Have more questions?

Call Julie Neiggmann, MSN, RN, Breast Cancer Nurse Navigator Santa Maria at 805-346-3405 or Carol Dichmann, RN, BSN, Oncology Nurse Navigator Arroyo Grande

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