NATIONAL CLINICAL PRACTICE GUIDELINE Breast Cancer Screening Clinical Practice Guideline Kaiser Permanente National Breast Cancer Screening Guideline Development Team This guideline is informational only. It is not intended or designed as a substitute for the reasonable exercise of independent clinical judgment by practitioners, considering each patient s needs on an individual basis. Guideline recommendations apply to populations of patients. Clinical judgment is necessary to design treatment plans for individual patients. August 2012
Guidelines Summary This guideline is informational only. It is not intended or designed as a substitute for the reasonable exercise of independent clinical judgment by practitioners, considering each patient s needs on an individual basis. Guideline recommendations apply to populations of patients. Clinical judgment is necessary to design treatment plans for individual patients. 1. Breast Cancer Risk Factors Asymptomatic women are considered to be at high risk if they have one or more of the following risk factors: 1A. Personal history of breast cancer (including ductal carcinoma in situ). 1B. Breast biopsy showing atypical hyperplasia or lobular neoplasia (lobular carcinoma in situ). Evidence-based: B 1C. First-degree relative diagnosed with breast cancer. * Evidence-based: B 1D. Women who have been tested and found to have a clinically significant alteration in a BRCA gene associated with increased risk for the development of breast cancer, or who have a first-degree relative who has been tested and found to have such an alteration, or a first- or second-degree relative with early-onset (diagnosis before age 50) breast cancer and/or ovarian cancer (at any age). 1E. Prior chest radiation therapy. * First-degree relative = parent, sibling, or child; Second-degree relative = aunt, uncle, grandparent, niece, nephew, or half sibling (National Cancer Institute, 2006 (1) ) 1 National Breast Cancer Screening Clincial Practice Guideline
2 Mammography Screening in Asymptomatic Women Without Breast Cancer Risk Factors 2A. Routine mammography screening is recommended for asymptomatic women aged 50-74. Evidence-based: B 2B. For women aged 75 and older, offer mammography in the context of a shared decisionmaking approach, taking into consideration life expectancy, patient preference, existing comorbidities, and clinician judgment. 2C. For women under age 40, routine mammography screening is not recommended. 2D. For women aged 40-49, offer mammography in the context of a shared decision-making approach, taking into consideration life expectancy, patient preference, existing comorbidities, and clinician judgment. 2E. The screening frequency for mammography is every 1-2 years. * * This recommendation takes into consideration the screening frequencies used in the large trials of mammography screening, which ranged from 12 to 33 months. 2 National Breast Cancer Screening Clincial Practice Guideline
3 Mammography Screening in Asymptomatic Women With Selected Breast Cancer Risk Factors 3A. Mammography screening is recommended for women with one or more of the following selected risk factors for breast cancer: Risk Factor: Begin Screening Personal history of breast cancer At age of diagnosis (including ductal carcinoma in situ) Breast biopsy showing atypical hyperplasia At age of diagnosis or lobular neoplasia (lobular carcinoma in situ) First-degree relative* diagnosed with breast cancer Genetic Risk: Clinically significant alteration in a BRCA1 or BRCA2 gene in the patient or a first-degree relative, or Family history of breast cancer in a first or second-degree relative (diagnosed before the age of 50) and/or ovarian cancer (diagnosed at any age) 5-10 years earlier than the affected family member s age at diagnosis, or by age 40 The year the alteration was found in the patient or 5-10 years earlier than the affected family member s age at diagnosis (but not before age 25), taking into consideration individual circumstances and patient preferences. Prior chest radiation therapy At age 25 3B. For women with risk factors for breast cancer, annual mammography screening is recommended. 4 Breast Self-Examination (BSE) 4A. Inform women of the lack of benefit and the potential harms of BSE. A shared decisionmaking approach to BSE that takes into account a woman s personal preferences and the balance of benefit to harm is recommended. 4B. Counsel all women to seek immediate medical attention upon detection of a breast lump. * First-degree relative = parent, sibling, or child; Second-degree relative = aunt, uncle, grandparent, niece, nephew, or half sibling (National Cancer Institute, 2006 (1) ) 3 National Breast Cancer Screening Clincial Practice Guideline
5 Clinical Breast Examination (CBE) 5 Offer CBE to asymptomatic women without breast cancer risk factors, in the context of a shared decision-making approach that takes into account a woman s personal preferences and the balance of benefit to harm. * 6 Clinical Breast Examination (CBE) for Asymptomatic Women with Breast Cancer Risk Factors 6A. CBE is recommended for women with the following selected risk factors for breast cancer: Risk Factor: Personal history of breast cancer (including ductal carcinoma in situ) Breast biopsy showing atypical hyperplasia or lobular neoplasia (lobular carcinoma in situ) First-degree relative diagnosed with breast cancer Genetic Risk: Clinically significant alteration in a BRCA1 or BRCA2 gene in the patient or a first-degree relative, or Family history of breast cancer in a first or second-degree relative (diagnosed before the age of 50) and/or ovarian cancer (diagnosed at any age) Begin Screening At age of diagnosis At age of diagnosis 5-10 years earlier than the affected family member s age at diagnosis, or by age 40 The year the alteration was found in the patient or 5-10 years earlier than the affected family member s age at diagnosis (but not before age 25), taking into consideration individual circumstances and patient preferences. Prior chest radiation therapy At age 25 6B. For women with risk factors for breast cancer, annual CBE is recommended. * CBE is not a prerequisite to obtaining a mammogram. The sensitivity of mammography in the general population is limited (71% to 96%), and CBE may detect additional breast cancers. The sensitivity of CBE ranges from 40% to 69%. First-degree relative = parent, sibling, or child; Second-degree relative = aunt, uncle, grandparent, niece, nephew, or half sibling (National Cancer Institute, 2006 (1) ) 4 National Breast Cancer Screening Clincial Practice Guideline
7 Magnetic Resonance Imaging (MRI) Screening for Asymptomatic Women without Breast Cancer Risk Factors 7 MRI screening is not recommended for asymptomatic women without breast cancer risk factors. * 8 Magnetic Resonance Imaging (MRI) Screening 8 MRI screening is an option for women at very high genetic risk (if the patient is not tested) as an adjunct to the other screening modalities of mammography, diagnostic ultrasound, and clinical breast examination (CBE). * There are currently no studies that determine the accuracy of MRI or its efficacy in reducing important health outcomes among women at average risk for developing breast cancer. Women at very high genetic risk are defined as those who have a clinically significant BRCA mutation or, in the absence of BRCA genetic test results, women with two first-degree relatives affected with breast or ovarian cancer, at least one of whom has invasive breast cancer diagnosed at < 40 years of age or ovarian cancer diagnosed at any age. Evidence shows that the sensitivity of MRI for tumor detection is higher than that of conventional mammography, but whether this difference in sensitivity has a direct effect on morbidity and/or mortality from breast cancer among patients screened by these methods remains uncertain. 5 National Breast Cancer Screening Clincial Practice Guideline