Original article
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

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Screening for breast cancer with mammography has been shown to decrease mortality from breast cancer, and mammography is the mainstay of screening for clinically occult disease. Mammography, however, has well-recognized limitations, and recently, other imaging including ultrasound and magnetic resonance imaging have been used as adjunctive screening tools, mainly for women who may be at increased risk for the development of breast cancer. The Society of Breast Imaging and the Breast Imaging Commission of the ACR are issuing these recommendations to provide guidance to patients and clinicians on the use of imaging to screen for breast cancer. Wherever possible, the recommendations are based on available evidence. Where evidence is lacking, the recommendations are based on consensus opinions of the fellows and executive committee of the Society of Breast Imaging and the members of the Breast Imaging Commission of the ACR.

Introduction

The significant decrease in breast cancer mortality, which amounts to nearly 30% since 1990, is a major medical success and is due in large part to the earlier detection of breast cancer through mammographic screening. Nevertheless, major efforts continue to build on this success by developing additional methods to screen for early breast cancer. Consequently, recommendations for breast cancer screening with imaging technologies have become increasingly complex. Several organizations, most notably the American Cancer Society (ACS) [1], have guidelines that are largely evidence-based, for how screening mammography should be used. In addition, the ACS has issued guidelines, also based predominately on existing evidence, for the use of magnetic resonance imaging of the breast to screen for breast cancer [2]. However, there are gaps in these guidelines, undoubtedly due to a lack of data concerning many aspects of the optimal utilization of available screening tests. To address some of these gaps, the Society of Breast Imaging (SBI) and the ACR, whose members are directly responsible for performing these screening tests, have performed and analyzed many of the trials establishing appropriate screening algorithms, and have the most expertise in these technologies, are issuing these guidelines and recommendations for breast cancer screening. Whenever possible, these are based on peer-reviewed published scientific data. Where data are lacking, the recommendations reflect expert consensus opinions by the fellows of the SBI and the members of the Breast Imaging Commission of the ACR. These guidelines and recommendations are intended to suggest appropriate utilization of imaging modalities for screening. They are not intended to replace sound clinical judgment and are not to be construed as representing the standard of care. It should be remembered that mammography is the only imaging modality that has been proven to decrease mortality from breast cancer.

The SBI and the ACR also wish to remind women and their physicians that in those instances in which there is a concern that risk for developing breast cancer is considerably elevated above that of the general population, consultation with appropriate experts in breast cancer genetics or high-risk management is desirable.

Section snippets

1. Mammography

  • Women at average risk for breast cancer

    • Annual screening from age 40

  • Women at increased risk for breast cancer

    • Women with certain BRCA1 or BRCA2 mutations or who are untested but have first-degree relatives (mothers, sisters, or daughters) who are proved to have BRCA mutations

      • Yearly starting by age 30 (but not before age 25)

    • Women with ≥20% lifetime risk for breast cancer on the basis of family history (both maternal and paternal)

      • Yearly starting by age 30 (but not before age 25), or 10 years

Screening Annually Beginning at Age 40

Evidence to support the recommendation for regular periodic screening mammography comes from the results of several randomized controlled trials (RCTs) conducted in Europe and North America [3, 4, 5, 6, 7, 8, 9, 10] that included a total of nearly 500,000 women. The trials varied in age of included women and in screening frequency, but all but 1 demonstrated statistically significant decreases in breast cancer mortality among the populations invited to screening. Overall, on the basis of a

Acknowledgments

We gratefully acknowledge the assistance received from Dr Robert Smith of the ACS and from the fellows of the SBI in formulating these recommendations. We also acknowledge the help of Pamela Wilcox of the ACR and Michele Wittling of the SBI, without whose assistance this document would not have been possible.

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    Disclosures: P. Evans, Hologic, Inc., consultant, Scientific Advisory Board. B. Monsees, Hologic, Inc., member, Advisory Board. L. Bassett, Hologic, Inc., consultant, Research Advisory Committee. W. Berg, Naviscan, Inc., consultant; Medipattern, Inc., consultant. E. Hendrick, GE Healthcare, consultant, member, Advisory Board; Koning, Corp., member, Advisory Board; Bracco Imaging, SpA, member, Advisory Board. E. Mendelson, Hologic, Inc., member, Medical Advisory Board; Siemens Medical Systems, investigator; Supersonic Imaging, investigator and speaker; Toshiba Ultrasound, speaker. C. D'Orsi, Hologic, Inc., consultant. L.W. Burhenne, Hologic, Inc., member, Advisory Committee.

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