Breast Cancer Screening

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Date of origin: 2012
Last review date: 2016

American College of Radiology
ACR Appropriateness Criteria®

Clinical Condition:         Breast Cancer Screening

 

Variant 1:                         High-risk women: women with a BRCA gene mutation and their untested first- degree relatives, women with a history of chest irradiation between the ages of 10–30, women with 20% or greater lifetime risk of breast cancer.

 

Radiologic Procedure Rating Comments RRL*
Beginning at age 25–30 or 10 years before
age of first-degree relative with breast
Mammography screening 9 cancer or 8 years after radiation therapy, ☢ ☢
but not before age of 25. Mammography
and MRI are complementary
examinations, both should be performed.
Beginning at age 25–30 or 10 years before
age of first-degree relative with breast
Digital breast tomosynthesis screening 9 cancer or 8 years after radiation therapy, ☢ ☢
but not before age of 25. Mammography
and MRI are complementary
examinations, both should be performed.
Mammography and MRI are O
MRI breast without and with IV contrast 9 complementary examinations, both should
be performed.
US breast 6 If patient cannot have MRI. O
FDG-PEM 2 ☢ ☢ ☢ ☢
Tc-99m sestamibi BSGI 2 ☢ ☢ ☢ ☢
MRI breast without IV contrast 1 O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

Variant 2:                         Intermediate-risk women: women with personal history of breast cancer, lobular neoplasia, atypical ductal hyperplasia, or 15%–20% lifetime risk of breast cancer.

 

Radiologic Procedure Rating Comments RRL*
Mammography and MRI are ☢ ☢
Mammography screening 9 complementary examinations. MRI should
not replace mammography.
Mammography and MRI are ☢ ☢
Digital breast tomosynthesis screening 9 complementary examinations. MRI should
not replace mammography.
Mammography and MRI are O
MRI breast without and with IV contrast 7 complementary examinations. MRI should
not replace mammography.
US breast 5 O
FDG-PEM 2 ☢ ☢ ☢ ☢
Tc-99m sestamibi BSGI 2 ☢ ☢ ☢ ☢
MRI breast without IV contrast 1 O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

Clinical Condition: Breast Cancer Screening
Variant 3: Average-risk women: women with <15% lifetime risk of breast cancer, breasts not dense.
Radiologic Procedure Rating Comments RRL*
Mammography screening 9 ☢ ☢
Digital breast tomosynthesis screening 9 ☢ ☢
MRI breast without and with IV contrast 3 O
US breast 2 O
MRI breast without IV contrast 1 O
FDG-PEM 1 ☢ ☢ ☢ ☢
Tc-99m sestamibi BSGI 1 ☢ ☢ ☢ ☢
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level
 

BREAST CANCER SCREENING
Expert Panel on Breast Imaging: Martha B. Mainiero, MD1; Lisa Bailey, MD2; Carl D’Orsi, MD3; Edward D. Green, MD4; Anna I. Holbrook, MD5; Su -Ju Lee, MD6; Ana P. Lourenco, MD7; Linda Moy, MD8; Karla A. Sepulveda, MD9; Priscilla J. Slanetz, MD, MPH10; Sunita Trikha, MD11; Monica M. Yepes, MD12; Mary S. Newell, MD.13

Summary of Literature Review

Mammography

Mammography is the only method of screening for breast cancer shown to decrease mortality [1- 4]. Annual screening mammography is recommended starting at: 1) age 40 for general population; 2) age 25-30 for BRCA (BReast CAncer 1) carriers and untested relatives of BRCA carriers; 3) age 25-30 or 10 years earlier than the age of the affected relative at diagnosis (whichever is later) for women with a first-degree relative with premenopausal breast cancer or for women with a lifetime risk of breast cancer ≥20% on the basis of family history; 4) 8 years after radiation therapy but not before age 25 for women who received mantle radiation between the ages of 10-30; and 5) any age for women with biopsy-proven lobular neoplasia, atypical ductal hyperplasia (ADH), ductal carcinoma in situ (DCIS), or invasive breast cancer [5]. However, mammography alone does not perform as well as mammography plus supplemental screening in certain subsets of women, particularly those with a genetic predisposition to the disease and those with dense breasts [6-11]. Therefore, supplemental screening is recommended in selected high-risk populations.

Digital Breast Tomosynthesis

Digital breast tomosynthesis (DBT) can address some of the limitations encountered with standard mammographic views. In addition to planar images, DBT allows for creation and viewing of thin-section reconstructed images that may decrease the lesion-masking effect of overlapping normal tissue, and reveal the true nature of potential false positive findings without the need for recall. Several studies confirm that in a screening setting, cancer detection rate is increased with use of DBT compared to 2-D mammography alone [12-27]. Additionally, the rate of recall for benign findings (false positives) can be decreased [12,14-17,20-25,27 -30]. Some authors found these advantages to be especially pronounced in women under age 50 [20,31], in those with dense breasts [31,32], and with lesion types including spiculated masses [33] and asymmetries [28]. Interpretation time for DBT images is greater than for standard mammography [14,34]. Additionally, dose is increased if standard 2-D images are obtained in addition to DBT images. However, synthesized reconstructed images (a virtual planar image created from the tomographic data set) may replace the need for a 2-D correlative view; and current data suggests that these synthetic images perform as well as standard full-field digital images [35,36].

Magnetic Resonance Imaging

Breast magnetic resonance imaging (MRI) in high-risk women has been shown to have a higher sensitivity than mammography, and the combination of mammography and MRI in this population has the highest sensitivity [37-44]. In a high- risk population, MRI and mammography combined have a higher sensitivity (92.7%) than ultrasound (US) and mammography combined (52%) [6]. Therefore, in high-risk women for whom supplemental screening is indicated, MRI is recommended when possible.

Screening high-risk women with breast MRI is cost-effective [45,46] and the cost-effectiveness of screening MRI increases with increasing breast cancer risk. The American Cancer Society recommends screening breast MRI in certain high-risk women [47], and the ACR and Society of Breast Imaging endorse those recommendations [5]. Screening MRI is recommended in women with BRCA gene mutations and their untested first-degree relatives as well as women with a lifetime risk of breast cancer of ~20% or greater. Also included in this high-risk group are women who have received radiation therapy to the chest between the ages of 10-30 as well as women with other

1Principal Author, Rhode Island Hospital, Providence, Rhode Island. 2Bay Area Breast Surgeons, Emeryville, California, American College of Surgeons. 3Emory University Hospital, Atlanta, Georgia. 4The University of Mississippi Medical Center, Jackson, Mississippi. 5Emory University Hospital, Atlanta, Georgia. 6University of Cincinnati, Cincinnati, Ohio. 7Rhode Island Hospital, Providence, Rhode Island. 8NYU Clinical Cancer Center, New York, New York. 9Baylor College of Medicine, Houston, Texas. 10Beth Israel Deaconess Medical Center, Boston, Massachusetts. 11 North Shore University Hospital, Manhasset, New York. 12University of Miami, Miami, Florida. 13Panel Chair, Emory University Hospital, Atlanta, Georgia.

The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.

Reprint requests to: publications@acr.org

genetic syndromes that increase the risk of breast cancer (eg, Li Fraumeni syndrome). For other women with an intermediate risk of breast cancer, such as those with a lifetime risk of 15%-20%, a personal history of breast cancer, or a history of lobular neoplasia or ADH, the use of screening MRI is an area of ongoing investigation [5,47]. However, recent literature supports the use of screening MRI in addition to mammography in patients with a personal history of breast cancer [48] and lobular neoplasia [49].

Ultrasound

Screening US is indicated in high-risk patients who cannot tolerate MRI. Supplemental screening with US for women with intermediate risk and dense breasts is an option to increase cancer detection. However, hand-held US screening by the radiologist has a high false-positive rate and is time -consuming [50]. Therefore, this may not be a cost-effective practice. The balance between cancer detection and the risk of a false positive result should be considered by women and their health care providers when considering the use of screening US or other ancillary screening examinations.

Other Imaging Modalities

There is insufficient evidence to support the use of other imaging modalities such as thermography, breast specific gamma imaging (BSGI), positron emission mammography (PEM), or optical imaging for breast cancer screening

  • Radiation dose from BSGI and PEM are 15-30 times higher than the dose of a digital mammogram [51,52], and they are not indicated for screening in their present form.

Summary of Recommendations

For high-risk women, annual screening mammography and contrast-enhanced MRI are both indicated. US can be used for patients with contraindications to MRI.

For intermediate-risk women, annual screening mammography is indicated. Contrast-enhanced MRI may be indicated in some patients.

For average-risk women, annual screening mammography is indicated.

Summary of Evidence

Of the 52 references cited in the ACR Appropriateness Criteria® Breast Cancer Screening document, all of them are categorized as diagnostic references including 9 well designed studies, 7 good quality studies, and 21 quality studies that may have design limitations. There are 13 references that may not be useful as primary evidence. There are 2 references that are meta-analysis studies.

The 52 references cited in the ACR Appropriateness Criteria® Breast Cancer Screening document were published from 1997-2015.

While there are references that report on studies with design limitations, 16 well designed or good quality studies provide good evidence.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, both because of organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared to those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

 

Relative Radiation Level* Adult Effective Dose Estimate Pediatric Effective Dose Estimate
Range Range
O 0 mSv 0 mSv
<0.1 mSv <0.03 mSv
☢ ☢ 0.1-1 mSv 0.03-0.3 mSv
☢ ☢ ☢ 1-10 mSv 0.3-3 mSv
☢ ☢ ☢ ☢ 10-30 mSv 3-10 mSv
☢ ☢ ☢ ☢ ☢ 30-100 mSv 10-30 mSv

 

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (eg, region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies”.

Supporting Documents

For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.

References

  1. Reduction in breast cancer mortality from organized service screening with mammography: 1. Further confirmation with extended data. Cancer Epidemiol Biomarkers Prev. 2006;15(1):45-51.
  2. Duffy SW, Tabar L, Chen HH, et al. The impact of organized mammography service screening on breast carcinoma mortality in seven Swedish counties. 2002;95(3):458-469.
  3. Hendrick RE, Smith RA, Rutledge JH, 3rd, Smart CR. Benefit of screening mammography in women aged 40-49: a new meta-analysis of randomized controlled trials. J Natl Cancer Inst Monogr. 1997(22):87-92.
  4. Tabar L, Vitak B, Chen HH, Yen MF, Duffy SW, Smith RA. Beyond randomized controlled trials: organized mammographic screening substantially reduces breast carcinoma mortality. 2001;91(9):1724-1731.
  5. Lee CH, Dershaw DD, Kopans D, et al. Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol. 2010;7(1):18-27.
  6. Berg WA. Tailored supplemental screening for breast cancer: what now and what next? AJR Am J 2009;192(2):390-399.
  7. Brekelmans CT, Seynaeve C, Bartels CC, et al. Effectiveness of breast cancer surveillance in BRCA1/2 gene mutation carriers and women with high familial risk. J Clin Oncol. 2001;19(4):924-930.
  8. Chart PL, Franssen E. Management of women at increased risk for breast cancer: preliminary results from a new program. 1997;157(9):1235-1242.
  9. Macmillan RD. Screening women with a family history of breast cancer–results from the British Familial Breast Cancer Group. Eur J Surg Oncol. 2000;26(2):149-152.
  10. Scheuer L, Kauff N, Robson M, et al. Outcome of preventive surgery and screening for breast and ovarian cancer in BRCA mutation carriers. J Clin Oncol. 2002;20(5):1260-1268.
  11. Warner E, Plewes DB, Shumak RS, et al. Comparison of breast magnetic resonance imaging, mammography, and ultrasound for surveillance of women at high risk for hereditary breast cancer. J Clin Oncol. 2001;19(15):3524-3531.
  12. Ciatto S, Houssami N, Bernardi D, et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol. 2013;14(7):583-589.
  13. Bernardi D, Caumo F, Macaskill P, et al. Effect of integrating 3D-mammography (digital breast tomosynthesis) with 2D-mammography on radiologists’ true-positive and false-positive detection in a population breast screening trial. Eur J Cancer. 2014;50(7):1232-1238.
  14. Bernardi D, Ciatto S, Pellegrini M, et al. Application of breast tomosynthesis in screening: incremental effect on mammography acquisition and reading time. Br J Radiol. 2012;85(1020):e1174-1178.
  15. Caumo F, Bernardi D, Ciatto S, et al. Incremental effect from integrating 3D-mammography (tomosynthesis) with 2D-mammography: Increased breast cancer detection evident for screening centres in a population-based trial. 2014;23(1):76-80.
  16. Friedewald SM, Rafferty EA, Rose SL, et al. Breast cancer screening using tomosynthesis in combination with digital mammography. 2014;311(24):2499-2507.
  17. Greenberg JS, Javitt MC, Katzen J, Michael S, Holland AE. Clinical performance metrics of 3D digital breast tomosynthesis compared with 2D digital mammography for breast cancer screening in community practice. AJR Am J Roentgenol. 2014;203(3):687-693.
  18. Houssami N, Macaskill P, Bernardi D, et al. Breast screening using 2D-mammography or integrating digital breast tomosynthesis (3D-mammography) for single-reading or double-reading–evidence to guide future screening strategies. Eur J Cancer. 2014;50(10):1799-1807.
  19. Lei J, Yang P, Zhang L, Wang Y, Yang K. Diagnostic accuracy of digital breast tomosynthesis versus digital mammography for benign and malignant lesions in breasts: a meta-analysis. Eur Radiol. 2014;24(3):595-602.
  20. McCarthy AM, Kontos D, Synnestvedt M, et al. Screening outcomes following implementation of digital breast tomosynthesis in a general-population screening program. J Natl Cancer Inst. 2014;106(11).
  21. Rafferty EA, Park JM, Philpotts LE, et al. Assessing radiologist performance using combined digital mammography and breast tomosynthesis compared with digital mammography alone: results of a multicenter, multireader trial. 2013;266(1):104-113.
  22. Rafferty EA, Park JM, Philpotts LE, et al. Diagnostic accuracy and recall rates for digital mammography and digital mammography combined with one-view and two-view tomosynthesis: results of an enriched reader study. AJR Am J Roentgenol. 2014;202(2):273-281.
  23. Rose SL, Tidwell AL, Ice MF, Nordmann AS, Sexton R, Jr., Song R. A reader study comparing prospective tomosynthesis interpretations with retrospective readings of the corresponding FFDM examinations. Acad 2014;21(9):1204-1210.
  24. Skaane P, Bandos AI, Gullien R, et al. Prospective trial comparing full-field digital mammography (FFDM) versus combined FFDM and tomosynthesis in a population-based screening programme using independent double reading with arbitration. Eur Radiol. 2013;23(8):2061-2071.
  25. Skaane P, Bandos AI, Gullien R, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. 2013;267(1):47-56.
  26. Svahn TM, Chakraborty DP, Ikeda D, et al. Breast tomosynthesis and digital mammography: a comparison of diagnostic accuracy. Br J Radiol. 2012;85(1019):e1074-1082.
  27. Takamoto Y, Tsunoda H, Kikuchi M, et al. Role of breast tomosynthesis in diagnosis of breast cancer for Japanese women. Asian Pac J Cancer Prev. 2013;14(5):3037-3040.
  28. Durand MA, Haas BM, Yao X, et al. Early clinical experience with digital breast tomosynthesis for screening mammography. 2015;274(1):85-92.
  29. Lourenco AP, Barry-Brooks M, Baird GL, Tuttle A, Mainiero MB. Changes in recall type and patient treatment following implementation of screening digital breast tomosynthesis. 2015;274(2):337-342.
  30. Rose SL, Tidwell AL, Bujnoch LJ, Kushwaha AC, Nordmann AS, Sexton R, Jr. Implementation of breast tomosynthesis in a routine screening practice: an observational study. AJR Am J Roentgenol. 2013;200(6):1401-1408.
  31. Haas BM, Kalra V, Geisel J, Raghu M, Durand M, Philpotts LE. Comparison of tomosynthesis plus digital mammography and digital mammography alone for breast cancer screening. 2013;269(3):694-700.
  32. Mun HS, Kim HH, Shin HJ, et al. Assessment of extent of breast cancer: comparison between digital breast tomosynthesis and full-field digital mammography. Clin Radiol. 2013;68(12):1254-1259.
  33. Lang K, Andersson I, Zackrisson S. Breast cancer detection in digital breast tomosynthesis and digital mammography-a side-by-side review of discrepant cases. Br J Radiol. 2014;87(1040):20140080.
  34. Dang PA, Freer PE, Humphrey KL, Halpern EF, Rafferty EA. Addition of tomosynthesis to conventional digital mammography: effect on image interpretation time of screening examinations. 2014;270(1):49-56.
  35. Skaane P, Bandos AI, Eben EB, et al. Two-view digital breast tomosynthesis screening with synthetically reconstructed projection images: comparison with digital breast tomosynthesis with full-field digital mammographic images. 2014;271(3):655-663.
  36. Zuley ML, Guo B, Catullo VJ, et al. Comparison of two-dimensional synthesized mammograms versus original digital mammograms alone and in combination with tomosynthesis images. 2014;271(3):664-671
  37. Hagen AI, Kvistad KA, Maehle L, et al. Sensitivity of MRI versus conventional screening in the diagnosis of BRCA-associated breast cancer in a national prospective series. 2007;16(4):367-374.
  38. Hartman AR, Daniel BL, Kurian AW, et al. Breast magnetic resonance image screening and ductal lavage in women at high genetic risk for breast carcinoma. 2004;100(3):479-489.
  39. Kriege M, Brekelmans CT, Boetes C, et al. Differences between first and subsequent rounds of the MRISC breast cancer screening program for women with a familial or genetic predisposition. 2006;106(11):2318-2326.
  40. Kuhl CK, Schrading S, Leutner CC, et al. Mammography, breast ultrasound, and magnetic resonance imaging for surveillance of women at high familial risk for breast cancer. J Clin Oncol. 2005;23(33):8469-8476.
  41. Leach MO, Boggis CR, Dixon AK, et al. Screening with magnetic resonance imaging and mammography of a UK population at high familial risk of breast cancer: a prospective multicentre cohort study (MARIBS). 2005;365(9473):1769-1778.
  42. Lehman CD, Isaacs C, Schnall MD, et al. Cancer yield of mammography, MR, and US in high-risk women: prospective multi-institution breast cancer screening study. 2007;244(2):381-388.
  43. Sardanelli F, Podo F, D’Agnolo G, et al. Multicenter comparative multimodality surveillance of women at genetic-familial high risk for breast cancer (HIBCRIT study): interim results. 2007;242(3):698-715
  44. Warner E, Plewes DB, Hill KA, et al. Surveillance of BRCA1 and BRCA2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination. 2004;292(11):1317-1325.
  45. Plevritis SK, Kurian AW, Sigal BM, et al. Cost-effectiveness of screening BRCA1/2 mutation carriers with breast magnetic resonance imaging. 2006;295(20):2374-2384.
  46. Taneja C, Edelsberg J, Weycker D, Guo A, Oster G, Weinreb J. Cost effectiveness of breast cancer screening with contrast-enhanced MRI in high-risk women. J Am Coll Radiol. 2009;6(3):171-179.
  47. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57(2):75-89.
  48. Brennan S, Liberman L, Dershaw DD, Morris E. Breast MRI screening of women with a personal history of breast cancer. AJR Am J Roentgenol. 2010;195(2):510-516.
  49. Sung JS, Malak SF, Bajaj P, Alis R, Dershaw DD, Morris EA. Screening breast MR imaging in women with a history of lobular carcinoma in situ. 2011;261(2):414-420.
  50. Berg WA, Blume JD, Cormack JB, et al. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. 2008;299(18):2151-2163.
  51. Hendrick RE. Radiation doses and cancer risks from breast imaging studies. 2010;257(1):246-253.
  52. O’Connor MK, Li H, Rhodes DJ, Hruska CB, Clancy CB, Vetter RJ. Comparison of radiation exposure and associated radiation-induced cancer risks from mammography and molecular imaging of the breast. Med 2010;37(12):6187-6198.