Seeking a woman in Brest county

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Read terms. Reaffirmed Regular screening mammography starting at age 40 years reduces breast cancer mortality in average-risk women 2. Screening, however, also exposes women to harm through false-positive test and overdiagnosis of biologically indolent lesions. Differences in balancing benefits and harms have led to differences among major guidelines about what age to start, what age to stop, and how frequently to recommend mammography screening in average-risk women 2 4.

Breast cancer risk assessment is very important for identifying women who may benefit from more intensive breast cancer surveillance; however, there is no standardized approach to office-based breast cancer risk assessment in the United States. This can lead to missed opportunities to identify women at high risk of breast cancer and may result in applying average-risk screening recommendations to high-risk women. Risk assessment and identification of women at high risk allow for referral to health care providers with expertise in cancer genetics counseling and testing for breast cancer-related germline mutations eg, BRCA , patient counseling about risk-reduction options, and cascade testing to identify family members who also may be at increased risk.

The purpose of this Practice Bulletin is to discuss breast cancer risk assessment, review breast cancer screening guidelines in average-risk women, and outline some of the controversies surrounding breast cancer screening. It will present recommendations for using a framework of shared decision making to assist women in balancing their personal values regarding benefits and harms of screening at various ages and intervals to make personal screening choices from within a range of reasonable options.

Recommendations for women at elevated risk and discussion of new technologies, such as tomosynthesis, are beyond the scope of this document and are addressed in other publications of the American College of Obstetricians and Gynecologists ACOG 5 6 7. It is estimated that , new cases of breast cancer, resulting in 40, deaths, will be diagnosed in women in the United States in 8.

An additional 63, new cases of ductal carcinoma in situ also will be diagnosed 8. Breast cancer mortality rates have decreased substantially during the past 50 years. This decrease has been attributed to early detection and improvements in breast cancer treatment 3. There are currently an estimated 3. Although other characteristics have been associated with an increased risk of breast cancer Box 1 6 10 11 12 13 , most women in whom invasive breast cancer is diagnosed do not have identifiable risk factors.

Family history of breast cancer, ovarian cancer, or other hereditary breast and ovarian syndrome- associated cancer eg, prostate cancer, pancreatic cancer. Certain reproductive factors influence breast cancer risk, particularly the risk of hormone receptor-positive breast cancer Box 1 6 10 11 12 A systematic review indicates that nulliparity and longer intervals between menarche and age at first birth are associated with an increased risk of hormone receptor-positive breast cancer Other less consistently reported reproductive risk factors for breast cancer include older age at first birth, older age at menopause, and younger age at menarche.

In contrast, certain reproductive factors appear to decrease the risk of breast cancer. Breast cancer risk appears to differ between postmenopausal women who use combined hormonal therapy and those who use estrogen therapy alone. In postmenopausal women who ly had a hysterectomy and were randomized to receive estrogen alone or placebo, breast cancer risk did not appear increased Family history of breast cancer, ovarian cancer including fallopian tube cancer and primary peritoneal cancer , and other types of germline mutation-associated cancer eg, prostate and pancreatic are associated with an increased risk of breast cancer.

For family members with cancer, breast cancer onset at a young age is associated with an increased risk of the presence of a germline mutation. For more information, see Practice Bulletin No. Atypical ductal hyperplasia, atypical lobular hyperplasia, and lobular carcinoma in situ are typically found incidentally upon histologic evaluation of abnormal mammography findings or breast masses Women with dense breasts diagnosed by mammography have a modestly increased risk of breast cancer.

Mammography has reduced sensitivity to detect breast cancer in women with dense breasts Breast cancer screening in women with dense breasts is beyond the scope of this document. For more information, see Committee Opinion No.

Women treated for Hodgkin lymphoma with therapeutic chest radiation therapy between the ages of 10 years and 30 years and possibly as late as age 45 years are at an increased risk of breast cancer 20 21 Girls who are treated between the ages of 10 years and 14 years appear to be at greatest risk of future development of breast cancer. The goal of screening for cancer is to detect preclinical disease in healthy, asymptomatic patients to prevent adverse outcomes, improve survival, and avoid the need for more intensive treatments.

Screening tests have both benefits eg, improved health outcomes and adverse consequences eg, cost, anxiety, inconvenience, false-positive , and other test-specific harms such as overdiagnosis and overtreatment. Breast self-examination, breast self-awareness, clinical breast examination, and mammography all have been used alone or in combination to screen for breast cancer.

In general, more intensive screening detects more disease. Screening intensity can be increased by combining multiple screening methods, extending screening over a wider age range, or repeating the screening test more frequently. However, more frequent use of the same screening test typically is associated with diminishing returns ie, repeating the test twice as often does not make it twice as effective and an increased rate of screening-related harms.

Determining the appropriate combination of screening methods, the age to start screening, the age to stop screening, and how frequently to repeat the screening tests require finding the appropriate balance of benefits and harms. Determining this balance can be difficult because some issues, particularly the importance of harms, are subjective and valued differently from patient to patient.

This balance can depend on other factors, particularly the characteristics of the screening tests in different populations and at different ages. Varying judgments about the appropriate balance of benefits and harms have led to differences among the major guideline group recommendations for breast cancer screening Table 1 3 4 The American College of Obstetricians and Gynecologists has reviewed these guidelines, their supporting evidence and rationale, and the recommendations for shared decision making embedded within them.

The next few sections of this Practice Bulletin present data on overall benefits and harms of mammography screening. To update its screening recommendations, the U. Preventive Services Task Force and the ACS recently conducted separate systematic reviews of the evidence for breast cancer screening in average-risk women 2 Studying the effect of mammography on mortality is methodologically challenging because of the large of women needed and long follow-up periods involved.

Randomized and observational studies provide important information but have different limitations. Both systematic reviews combined randomized and observational studies and agreed that mammography generally decreases breast cancer mortality. The ACS systematic review noted that the magnitude of the mortality reduction varied across study types and duration of follow-up 2.

The ACS systematic review reported that screening mammography was associated with a decreased risk of breast cancer mortality in randomized controlled trials relative risk [RR], 0. The U. Preventive Services Task Force evidence review 24 reported by age Table 2 3. This systematic review also found a reduced risk of advanced breast cancer stage IIB or greater with screening mammography in women 50 years and older RR, 0.

Although the ACS and U. Preventive Services Task Force systematic reviews did not present evidence that screening mammography prevents the need for advanced cancer treatment, it is reasonable to assume that if screening reduces the risk of advanced breast cancer, it may reduce the need for advanced cancer treatment.

The ACS systematic review also examined the effect of screening mammography on life expectancy. Although the review concluded that there was high-quality evidence that mammographic screening increases life expectancy by decreasing breast cancer mortality, the authors were not able to estimate the size of the increase False-positive test from mammography include callbacks for additional images and follow-up biopsies that are found to be benign. Preventive Services Task Force conducted a systematic review specifically looking at harms associated with breast cancer screening in average-risk women The ACS systematic review 2 included a different analysis of the same data In this analysis, certain patient factors such as combination hormone therapy use and dense breasts were associated with an increased likelihood of false-positive test among women aged 40—49 years.

Preventive Services Task Force systematic review on the harms of breast cancer screening found that women who received clear communication of negative test reported minimal anxiety, whereas those called back for further testing reported increased anxiety, breast cancer-specific worry, and distress In some women, anxiety and distress persisted despite negative test on the follow-up testing. Two studies reported that women with false-positive test were less likely to return for their next screening mammography.

False-positive test also have financial costs, which often need to be paid all or in part by the patient. Preventive Services Task Force systematic review noted that many women reported pain during mammography; however, few considered it a deterrent to future screening Overdiagnosis occurs when screening detects cancer that would not have progressed to symptomatic cancer if left undetected Thus, overdiagnosis is the identification of cancer that remains indolent. Overtreatment is defined as the initiation of treatment for an overdiagnosed cancer.

It is difficult to determine the true rate of overdiagnosis because it is not ethically permissible to conduct natural history studies of untreated disease, so a variety of indirect methodologies have been used to estimate its frequency 28 29 There is ificant uncertainty as to how often breast cancer overdiagnosis occurs. Reported rates of overdiagnosis and overtreatment are, in part, related to the management of ductal carcinoma in situ. This lesion has a ificantly lower risk than breast cancer, although many studies group it with breast cancer and its diagnosis typically le to treatment.

Preventive Services Task Force evidence review reported similar based on observational trial data, but arrived at higher estimates ranging from Modeling data also indicate that the risk of overdiagnosis appears to be lower with older age and with less frequent screening Research to develop better prognostic indicators of progressive versus nonprogressive ductal carcinoma in situ and other lesions may allow more customized treatment in the future, thereby reducing overtreatment 3.

Preventive Services Task Force systematic review found no direct studies of radiation exposure from mammography but included a modeling study that estimated that the of deaths caused by mammography radiation-induced cancer was 2 per , among women aged 50—59 years screened biennially, and 11 per , among women aged 40—49 years screened annually A more recent modeling study estimated that the potential mortality benefit of early breast cancer detection through annual screening starting at age 40 years far outweighed by fold the risk of dying from mammography radiation-induced cancer In this model, radiation from annual screening of , women aged 40—74 years was estimated to induce cases of breast cancer and 16 cases of breast cancer deaths, compared with cases of cancer deaths prevented by early detection through screening.

Shared decision making is a process in which patients and physicians share information, express treatment preferences, and agree on a treatment plan see Committee Opinion No. It combines the expertise of the physician, who provides the details of the clinical information, including the benefits eg, decreased risk of dying of breast cancer and harms eg, callbacks, benign breast biopsies, overdiagnosis , and the values of the patient, who shares her experiences, concerns, and priorities. The clinical information can be provided in ways that are efficient for patients and physicians eg, online videos or reliable web s, informational handouts, or face-to-face conversations.

Shared decision making is particularly important for decisions regarding breast cancer screening because many choices involve personal preferences related to potential benefits and adverse consequences. Breast cancer risk assessment is based on a combination of the various factors that can affect risk Box 1 6 10 11 12 Initial assessment should elicit information about reproductive risk factors, of prior biopsies, ionizing radiation exposure, and family history of cancer.

Health care providers should identify cases of breast, ovarian, colon, prostate, pancreatic, and other types of germline mutation-associated cancer in first-degree, second-degree, and possibly third-degree relatives as well as the age of diagnosis. Women with a potentially increased risk of breast cancer based on initial history should have further risk assessment.

Risk assessment is important to determine if a woman is at average or increased risk of breast cancer to guide counseling regarding breast cancer surveillance, risk reduction, and genetic testing. Risk assessment should not be used to consider a woman ineligible for screening appropriate for her age. Rather, risk assessment should be used to identify women who may benefit from genetic counseling, enhanced screening such as magnetic resonance imaging screening, more frequent clinical breast examinations, or risk-reduction strategies.

Information regarding screening and risk reduction for women at high risk is discussed elsewhere 4 5 35 A of validated breast cancer risk assessment tools are readily available online and can be completed quickly in an office setting. Some tools are better for certain risk factors and populations than others. The Gail model www. It is of limited use in some women, including those younger than 35 years, those with a family history of breast cancer in paternal family members or in second-degree or more distantly related family members, those with family histories of nonbreast cancer eg, ovarian and prostate known to be associated with genetic mutations, and high-risk lesions on biopsy other than atypical hyperplasia eg, lobular carcinoma in situ.

One study showed that the IBIS model was more accurate for assessing breast cancer risk based on family history than the Claus or Gail model A hereditary cancer risk assessment is conducted by a genetic counselor or other health care provider with expertise in cancer genetics and includes gathering family history information, risk assessment, education, and counseling This assessment may include genetic testing, if desired, after appropriate counseling and informed consent is obtained.

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