Develop Your Breast Cancer Screening Plan Using These 7 Steps

Let’s start out by just saying that being screened for breast cancer is important. The reason that it’s important is because appropriate screening can decrease your risk of dying from breast cancer by up to 20%.¹ Over 40,000 women die of breast cancer every year, which is second only to lung cancer in the number of cancer deaths in women.² But in addition to the lives lost, breast cancer affects our society in many different ways. Here are some other statistics: 

• Close to a quarter of a million women are diagnosed with breast cancer every year in the United States. 
• It is the most common cancer to be diagnosed in women, excluding skin cancers. 
• Approximately one out of every eight women will be diagnosed with breast cancer sometime during their life.²

Most of us know someone close to us who has had breast cancer. This disease burdens many patients and their families, and has a devastating impact.

So, with this in mind, let it sink in that very few women fully understand the recommendations for breast cancer screening. There is rampant confusion about cancer screenings in general, but the confusion over breast cancer screening is complicated by the fact that many of the medical societies themselves disagree on what constitutes appropriate screening. This article will attempt to provide you with step-by-step guidance in how you should approach breast cancer screening, so that you know your options, can make an informed decision, and reduce your risk.

First, you need to figure out if you are average, moderate, or high risk. The first 5 steps, listed here, will help you with this.

Step 1: Answer the following four questions:  

• Do you have a history of ovarian, peritoneal (including tubal), or breast cancer?
• Does someone related to you (a “blood relative”) have a history of breast, ovarian, or peritoneal cancer?
• Have you ever had radiation therapy to the chest between age 10 and age 30?
• Do you or a blood relative have a known genetic predisposition (such as a BRCA mutation, or other genetic problems that increase your risk of developing breast cancer)? 

If you answered “no” to all of these, you are likely to be in the “average risk” category.⁴ You can skip to step 5. If you answered “yes”, move on to step 2.

Step 2: Use a risk prediction tool to determine if you would benefit from genetic counseling. “Risk prediction tools” are questionnaires that evaluate breast cancer risk. There are several such tools, but the ones that are probably utilized the most are the Pedigree Assessment Tool and the Ontario Family History Risk Assessment Tool (links provided below). Their main purpose is to help determine if referral to a genetic counselor for a more detailed risk analysis is appropriate. If you answered the questionnaire and you scored above the threshold, you may benefit from genetic counseling (step 3).⁴ Present these concerns to your doctor, and discuss a referral. If you scored below the threshold, you can skip to step 5. 

Pedigree Assessment Tool

Ontario Family History Risk Assessment Tool

Step 3: Genetic counseling. A genetic counselor will go through your family history, and assess the probability that you have a gene mutation that increases breast cancer risk. The most well-known of these is the BRCA gene mutation, but there are others as well. After analysis, the genetic counselor will be able to explain your options for genetic testing, which actually looks at your DNA to see if you have gene mutations. There are a lot of factors considered before genetic testing is ordered, and there is a very good chance that after counseling, it won’t be recommended for you. If this is the case, then you can now skip to step 5. 

Step 4: Genetic testing. At this point you’ve gone through genetic counseling, and it has been recommended that you undergo analysis of your DNA. If you do have a genetic condition that makes it more likely to develop a cancer, this is important to know. For example, let’s take the BRCA gene. The BRCA gene directs your body to notice when cells are becoming cancerous, and replicating out of the constraints of normal cellular activity. Normally, this will allow your body to repair malfunctioning DNA and prevent it from turning into a cancer. If you have a mutation on the BRCA gene, this process is less effective.⁵ 

Only 5 to 10% of breast cancers are caused by genetic issues.⁶ But, if you are one of the rare people with genetic predisposition, then you are at higher risk and need to be counseled on a high-risk screening and prevention plan. You will need to ignore the screening recommendations that will be discussed later in this article, and follow a plan that is catered to you specifically. For example, you may need to start screening earlier, utilize breast MRI as a screening tool, take medications to reduce your risk, or possibly be as aggressive as having surgery to remove breast tissue and ovaries. Fortunately, the vast majority of people do not have this level of risk. 

Step 5: Look at additional factors that could affect your breast cancer risk. Other than family history and genetics, there are other factors which could increase your risk. Many of these factors have to do with life events that alter the amount of estrogen that you’re exposed to throughout your life. A simple tool that can help estimate this risk is the “Gail model“.⁴ It may give you some more insight into whether you are in the “moderate” or “average” risk category. You’ll see why this is important to know in step 6.

“Moderate” risk is between 15 and 20% estimated lifetime risk of breast cancer. Anything below 15% is considered “average” risk.⁴ Keep in mind though, once again, that even average-risk patients have around a 12% lifetime risk, or one in eight.

Step 6: Decide which screening schedule is right for you. Now that you’ve established your risk, you have decisions to make for your screening. We have already discussed that if you are high-risk, you need to seek out or be referred to a high-risk clinic to discuss options and come up with a specific high-risk plan. For the rest of you, here are the recommendations from the medical societies that review evidence, and provide best-practice screening recommendations: 

The United States Preventive Services Task Force (USPSTF) recommends breast cancer screening by mammography biennially (every two years) for women aged 50-74 years of age. Additionally, for women between 40 and 49 years of age, a patient may decide (with their doctor) to screen as well, noting that the benefit is less pronounced, and the risks of false positives are higher.⁷ To view the USPSTF recommendations, click here. 

ACOG and several other groups disagree with this, and recommend annual mammograms starting at the age of 40, and continuing until at least the age of 75 in most women. They have softened their stance somewhat (as of June 2017), to support shared decision-making, especially in the 40-49 age group.⁸  To view the ACOG recommendations, click here. 

And not to be outdone, the American Cancer Society (ACS) has their own set of recommendations: Annual mammograms between the ages of 45 and 55, shared medical decision making between the ages of 40-44 regarding annual mammograms, and then biennial mammograms between the ages of 55-75 with shared medical decision making after that.⁹ To view the ACS recommendations, click here. 

Is it any wonder that women are confused about screening recommendations?

The rationale for this disagreement is that in the age group of 40 to 49, the benefits of cancer screening are lower, and the risks of “false alarms” are higher. Comparatively, in the older age groups (50-75), the number of lives saved is higher, and false positives are lower. False positives lead to more biopsies, studies, costs, stress and anxiety, and unnecessary treatment.³  The same concept applies when comparing annual mammograms versus biennial mammograms, as there is some benefit with annual screening, but more risk of false positives. It’s sort of a “robbing Peter to pay Paul“ situation. If you follow USPSTF guidelines, you will have less of a risk of being overdiagnosed, needing unnecessary biopsies, and being exposed to the radiation associated with mammogram. But it’s more possible you may miss diagnosing a cancer early. If you follow ACOG’s more aggressive guidelines, you would catch more cancers, but would face an increased risk of false positives.

These societies do share some common ground, in that they acknowledge that the benefit of screening is greatest between the ages of 50 to 69. They also advocate for shared medical decision-making between patients and their physicians, and they all agree that patients have a right to know potential risks before they undergo screening. 

This is why it’s important to know your risk. For example, if you fall into the “moderate” risk category, you may consider being more aggressive with earlier and more frequent screenings. Some women feel more comfortable with the aggressive approach regardless of whether they are “moderate” or “average” risk. Alternatively, if you are average risk, you may decide that the more conservative, USPSTF guidelines are right for you. You should discuss all of this with your doctor, but ultimately the decision is up to you. Which leads us to…

Step 7: Get your screenings done. Now that you’ve done all of this work to come up with a screening plan, stick to it! Ask your doctor’s office to help keep you accountable, and remind you when you will be due for another screening. You should consider creating your own “backup” reminders as well. The more layers of accountability, the better! 

Please pass this on to a woman that you know and love to make sure they’re well-informed on this issue. A better-educated population could lead to improvements in early detection. When this is combined with the efforts of our rockstar oncologists, surgeons, and breast cancer treatment teams, more women can be saved. This will lead to less heartbreak, and more triumph in the battle against breast cancer. 

Resources:

1. PubMed. The benefits and harms of breast cancer screening: an independent review. Independent UK Panel on Breast Cancer Screening. Lancet. 2012 Nov;380(9855):1778-86. Epub 2012 Oct 30. 
2.  U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2014 Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2017. Via www.cdc.gov/cancer/breast/statistics/index.htm.
3. Welch HG, Passow HJ. Quantifying the benefits and harms of screening mammography. JAMA Intern Med 2014; 174:448. Copyright © 2014 American Medical Association.
4. Joann G Elmore, MD, MPH. Screening for Breast Cancer: Strategies and Recommendations. Retrieved from: https://www.uptodate.com/contents/screening-for-breast-cancer-strategies-and-recommendations. Accessed April 25th, 2018. Most recent update: January 23, 2018. 
5. National Cancer Institute. BRCA Mutations: Cancer Risk and Genetic Testing. Retrieved from: https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet. Accessed May 16th, 2018. Most recent update: January 30, 2018. 
6. American Cancer Society. Breast Cancer Facts & Figures, 2015-2016.
7. Final Recommendation Statement: Screening Breast Cancer. U.S. Preventive Services Task Force. January 2016. www.uspreventiveservicestaskforce.org
8. ACOG Revises Breast Cancer Screening Guidance: Ob-Gyns Promote Shared Decision Making. American College of Obstetricians and Gynecologists. June 22, 2017. www.acog.org. 
9. American Cancer Society Breast Cancer Screening Guideline. American Cancer Society. July 7, 2017. www.cancer.org.