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Screening for Breast Cancer in Women at Average Risk

Guidelines Being Compared:

  1. American College of Obstetricians and Gynecologists (ACOG). Breast cancer screening. American College of Obstetricians and Gynecologists (ACOG); 2011 Aug. 11 p. (ACOG practice bulletin; no. 122). [54 references]
  2. Kaiser Permanente Care Management Institute (KPCMI). Breast cancer screening clinical practice guideline. Oakland (CA): Kaiser Permanente Care Management Institute; 2010 Aug. 142 p. [112 references]
  3. U.S. Preventive Services Task Force (USPSTF). 1) Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. 2) December 2009 addendum. Ann Intern Med 2009 Nov 17;151(10):716-726, W-236. [32 references]

A direct comparison of the recommendations presented in the above guidelines for screening for breast cancer in asymptomatic women at average risk is provided in the tables below. Recommendations for women at increased risk of breast cancer are beyond the scope of this synthesis.

Areas of Agreement

Mammographic Screening in Women Aged 50 to 74

All of the guideline developers recommend routine screening mammography in asymptomatic, average-risk women aged 50 to 74. With regard to frequency of screening in these women, USPSTF recommends biennial screening; KPCMI recommends an interval of one to two years; and ACOG recommends screening be offered annually. ACOG acknowledges that biennial screening may be a more appropriate or acceptable strategy to some women, and recommends the screening strategy should therefore be determined based on the patient's individual risk and values.

Mammographic Screening in Women Aged 75 and Older

ACOG and KPCMI agree that women aged 75 years and older should decide whether or not to continue screening in consultation with their physician, as part of a shared decision-making approach. USPSTF found insufficient evidence to assess the additional benefits and harms of screening mammography in women 75 years or older.

Digital Mammography and Magnetic Resonance Imaging (MRI)

ACOG and KPCMI agree that breast MRI is not recommended for screening women at average risk of developing breast cancer. USPSTF concluded that the current evidence is insufficient to assess the additional benefits and harms of using either digital mammography or MRI instead of film mammography as a screening modality for breast cancer. ACOG and KPCMI do not provide recommendations on digital mammography, but ACOG states that a recent meta-analysis of data from eight large randomized studies found that, overall, digital mammography demonstrated a slightly higher detection rate than film mammography, particularly for women aged 60 years or younger.

Areas of Difference

Mammographic Screening in Women Aged 40 to 49

ACOG recommends that women aged 40 years and older be offered screening mammography annually. ACOG acknowledges that biennial screening may be a more appropriate or acceptable strategy to some women, and recommends the screening interval should therefore be based on the patient's individual risk and values.

In contrast, KPCMI and USPSTF do not recommend routine screening mammography in women aged 40 to 49, but rather recommend that clinicians—in the context of a shared decision-making approach with the patient—base screening decisions on the potential benefits and harms, as well as on a woman's preferences, values, and individual risk profile.

Clinical Breast Examination (CBE)

ACOG recommends that CBE be performed every 1 to 3 years for women aged 20 to 39 years, and annually for women aged 40 years and older. The USPSTF guideline addresses only women aged 40 years or older, and in contrast to ACOG, concluded that the current evidence is insufficient to assess the additional benefits and harms of CBE beyond screening mammography in these women. KPCMI recommends CBE be offered 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.

Breast Self-Examination (BSE) and Breast Self-Awareness

USPSTF recommends against teaching BSE. According to ACOG, there is an evolution away from teaching BSE toward the concept of breast self-awareness, defined as women's awareness of the normal appearance and feel of their breasts. ACOG recommends that breast self-awareness be encouraged and can include BSE. Women who desire to perform self-examination as a part of this breast self-awareness strategy may be instructed in the appropriate technique, ACOG adds, although emphasis is not on examination techniques. KPCMI recommends that physicians inform women of the lack of benefit and the potential harms of BSE, and that women base the decision to perform BSE on a shared decision-making approach that takes into account their personal preferences and the balance of benefit to harm.

Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Screening for breast cancer in women at average risk. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 1998 Dec (revised 2012 Dec). [cited YYYY Mon DD]. Available: http://www.guideline.gov.