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US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Clinician's Handbook of Preventive Services

Clinician's Handbook of Preventive Services. 2nd edition.

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36Mammography

Breast cancer is the most common type of cancer in women and the second leading cause of cancer death in American women after lung cancer. The American Cancer Society predicts that there will be an estimated 180,200 new cases of breast cancer in women and 43,900 related deaths in 1997. In the United States, a woman's average lifetime risk for developing breast cancer is approximately one in eight. Breast cancer mortality increases with age. Mortality from breast cancer does not plateau, even in extreme old age. After age, the next strongest risk factor is a family history of breast cancer in a first-degree relative (sister or mother). Very modest increases in risk are also associated with nulliparity, first pregnancy after 30 years of age, menarche before 12 years of age, menopause after 50 years of age, postmenopausal obesity, some types of benign breast disease, high socioeconomic status, and a personal history of ovarian or endometrial cancer.

Mortality from breast cancer is strongly influenced by stage at detection. The 5-year survival rate for women in whom local disease is found is 96%. In contrast, the 5-year survival rate for women with distant metastasis is only 20%. Survival rates at every stage of diagnosis are lower among African-American women compared with Caucasian women.

Mammography is the most effective approach to early detection of breast cancer and is associated with sensitivity of 70% to 90% and specificity of 90% to 95%. Although mammography can detect small tumors in younger women, controversy exists regarding whether mammography screening reduces mortality in women younger than age 50 years.

Well-maintained, modern mammography equipment is very safe, requiring very low levels of radiation. Screening does, however, carry the added risk of morbidity attributable to any unnecessary biopsies that are performed following false-positive mammography results.

See chapter 30 for information about clinical breast examination to detect breast cancer.

Recommendations of Major Authorities

Women Aged 50 Years and Older

  • American Academy of Family Physicians (AAFP), American Cancer Society (ACS), American College of Obstetricians and Gynecologists (ACOG), American College of Physicians (ACP), American College of Preventive Medicine (ACPM), American Medical Association, Canadian Task Force on the Periodic Health Examination (CTFPHE), National Cancer Institute (NCI) and the US Preventive Services Task Force (USPSTF) --
  • Routine mammography screening is recommended. Yearly screening is recommended by ACS, ACOG and CTFPHE. AAFP, ACP, ACPM, NCI, and USPSTE recommend a frequency of 1 to 2 years. The CTFPHE, AAFP and USPSTF recommend screening until 70 years of age. The AAFP and USPSTF indicate that there is insufficient evidence to recommend for or against screening of women 70 years of age or older, although recommendations for this can be made on other grounds for women in this age category with a reasonable life expectancy. ACPM advises that women aged 70 or older should continue undergoing mammography screening provided their health status permits breast cancer treatment. ACP states that the use of mammography above 75 years of age should be discouraged. The American Geriatrics Society recommends that women over 65 years of age receive mammograms at least every 2 or 3 years until at least 85 years of age.

Women Under 50 Years of Age

  • American Academy of Family Physicians --
  • Recommends counseling about potential risks and benefits of mammography and clinical breast exam for women ages 40 to 49 years.
  • American Cancer Society (ACS), American College of Obstetricians and Gynecologists (ACOG), American Medical Association (AMA), and National Cancer Institute (NCI) --
  • The ACS recommends that women begin annual mammography at age 40. ACOG, NCI, and the AMA recommend screening mammograms every 1 to 2 years for women 40 to 49 years of age.
  • American College of Physicians and Canadian Task Force on the Periodic Health Examination --
  • Women under 50 should not be screened.
  • American College of Preventive Medicine and US Preventive Services Task Force --
  • There is insufficient evidence to recommend for or against routine screening in this age group, but screening high risk younger women may be appropriate despite the lack of direct evidence of benefit.
  • National Institutes of Health Consensus Development Panel on Breast Cancer Screening for Women Ages 40 to 49 (an independent panel) --
  • Currently available data does not warrant a universal recommendation for mammography for all women in their forties. Each woman should decide whether to undergo mammography.

High-Risk Women

  • American College of Obstetricians and Gynecologists --
  • Women with a family history of premenopausally diagnosed breast cancer in a first-degree relative should have mammography regularly beginning at 35 years of age.
  • American College of Physicians --
  • High-risk women should receive the same recommendations as average-risk women, unless a woman expresses great anxiety about breast cancer and insists on more intensive screening.
  • American College of Preventive Medicine and US Preventive Services Task Force --
  • Although there is no direct evidence evaluating mammography in high-risk women under 50 years of age, recommendations for screening such women can be made on other grounds. Women at high risk include those with a family history of premenopausal breast cancer in a first-degree relative or those with a history of breast and/or gynecologic cancer.
  • Canadian Task Force on the Periodic Health Examination --
  • Physicians may elect to recommend mammography starting at age 35 for women at high risk, especially those whose first-degree relatives have had breast cancer diagnosed before menopause.

Basics of Mammography Screening

1.

Emphasize the importance of mammography. A major reason reported by patients for not undergoing mammography is that they did not know they needed a mammogram. Counsel women on the need for regular mammography, not just one mammogram.

2.

Use pamphlets, videotapes, and other media to educate and motivate patients to receive mammographic screening.

3.

Because cost can be a significant barrier to patients obtaining mammography, the clinician should be knowledgeable about low-cost, high-quality mammography facilities available in the community and should make referrals to these facilities as needed. For information on the availability of low cost mammography at accredited facilities, contact your local office of the American Cancer Society or call the national toll-free number: (800)ACS-2345.

4.

Instruct the patient to wear pants or a skirt, because she will have to undress from the waist up. Instruct her to avoid use of deodorants, powders, or other topical agents on the breasts or in underarm areas, because these may cause artifacts on the mammogram.

5.

Because of potential perimenstrual breast tenderness, scheduling mammography at other times in the patient's menstrual cycle is preferred.

6.

Patients commonly experience mild discomfort during mammography. Instruct patients to tell the technician if the level of discomfort becomes unacceptable.

7.

Verify that mammography facilities use only dedicated mammography equipment that meets minimum safety and image-quality standards. Facilities that receive Medicare reimbursement must use equipment that complies with minimum standards for patient safety. The American College of Radiology provides certification for compliance with minimum standards for image quality. As of October 1, 1994, all US mammography facilities must be certified by the Food and Drug Administration (FDA) as providing quality mammography. Certification requirements cover personnel, equipment, radiation exposure, quality assurance programs, and record-keeping and reporting. Further information on this program is available from the FDA Center for Devices and Radiological Health, Office of Training and Assistance, Division of Mammography Quality and Radiation Programs, HFZ-240, 5600 Fishers Ln, Rockville, MD 20857.

8.

Establish a tracking system to ensure that mammograms that are ordered are actually performed, that results return in a timely fashion, and that patients who are not seen frequently can be called or contacted by letter about the importance of getting mammograms and other needed preventive care. Encourage patients to keep track of and prompt their own mammography through use of a patient-held record form or card.

9.

Any palpable breast lump, even with a normal mammogram, requires careful evaluation, including possible biopsy.

Patient Resources

  • Breast Cancer: Steps to Finding Breast Lumps Early. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org
  • Mammography. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com
  • What You Need To Know About Breast Cancer; A Mammogram Once a Year for Life; Smart Advice for Women 40 and Over: Have a Mammogram. Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A24, Bethesda, MD 20892; (800)4-CANCER.
  • Chances are You Need a Mammogram; Are you age 50 or Older? A Mammogram Could Save Your Life. Available in both English and Spanish. Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; (800)4-CANCER. Internet address: http://cancernet.nci.nih.gov

Provider Resources

  • Mammography. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com
  • Educating Older Women About Mammography: A Guide For Program Planners and Volunteer Leaders. American Association of Retired Persons, 1909 K Street, NW, Washington, DC 20049; (202)434-2277.
  • Detecting and Treating Breast Problems. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024-2188; (202)638-5577. Internet address: http://www.acog.com
  • Mammography Awareness Kit. Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; (800)4-CANCER. Internet address: http://cancernet.nci.nih.gov
  • OncoLink — The University of Pennsylvania Cancer Resource. Internet address: http://cancer.med.upenn.edu
  • PDQ: The Physician Data Query System for Cancer Information. PDQ is the National Cancer Institute's computerized database providing the most up-to-date cancer information available. Access to the system can be gained 24 hours a day, 7 days a week, using a personal computer and standard telephone line, or through medical libraries. Ask a medical librarian for assistance or call (800)4-CANCER (line 3). In Hawaii, on Oahu, call 524-1234.

Selected References

  1. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination . Kansas City, Mo: American Academy of Family Physicians; 1997.
  2. American Cancer Society. Cancer Facts & Figures-1997 . Atlanta, Ga: American Cancer Society; 1997.
  3. American Cancer Society. Summary of American Cancer Society recommendations for the early detection of cancer in asymptomatic people. CA . 1993; 43:–.
  4. American College of Obstetricians and Gynecologists. Guidelines for Women's Health Care . Washington, DC: American College of Obstetricians and Gynecologists; 1996.
  5. American College of Physicians. Guidelines. In: Eddy DM, ed. Common Screening Tests. Philadelphia, Pa: American College of Physicians; 1991:411-412.
  6. American Geriatrics Society, Clinical Practice Committee. Screening for breast cancer in elderly women. J Amer Geriatr Soc . 1989; 37:883–884. [PubMed: 2760383]
  7. American Medical Association, Council on Scientific Affairs. Mammographic screening in asymptomatic women aged 40 years and older. JAMA . 1989; 261:2535–2542. [PubMed: 2649703]
  8. Breast Cancer Screening for Women Ages 40-49. NIH Consensus Statement. 1997; Jan 21-23; 15(1):1-35.
  9. Canadian Task Force on the Periodic Health Examination. Screening for breast cancer. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 65.
  10. Eddy DM. Screening for breast cancer. In: Eddy DM, ed. Common Screening Tests. Philadelphia, Pa: American College of Physicians; 1991: chap 9.
  11. Eddy DM, Gordon MA, Bredt A. Screening for breast cancer. Ann Intern Med. In press.
  12. Ferrini R, Mannino E, Ramsdell E, et al. Screening mammography for breast cancer: American College of Preventive Medicine. Am J Prev Med. . 1996; 12(5):340–341. [PubMed: 8909643]
  13. National Cancer Institute. Cancer Facts: Questions and Answers About Mammography Screening. Bethesda, Md: National Institutes of Health; 1997.
  14. US Preventive Services Task Force. Screening for breast cancer.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 7.

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