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3. Screening/Early Detection

Updated August 2015

About one in eight women living to age ninety will eventually be diagnosed as having breast cancer. Risk increases with advancing age. 

3.1 Breast Self-examination

Women may do regular breast self-examination (BSE). For premenopausal women, this is best done in the week following the menstrual period. For postmenopausal women, a specific day of the month should be chosen. 

If done, the examination should include inspection of the breast and palpation of the breast and axilla. To perform adequate BSE the patient needs instruction in the technique and the manner in which she is carrying this out. This should be checked at subsequent examinations by her family physician.

There is no evidence that BSE improves survival, but regular self-examination does allow a woman to know her own body and therefore recognize early changes in the breast texture or appearance.  She should be encouraged to bring any concerns to her health care provider. 

3.2 Screening physical exam by Family Physician

The combination of physical examination by a physician and mammographic screening has been shown to reduce mortality from breast cancer. The relative importance of the physical examination vis-a-vis the mammogram remains unclear. As 10% of breast cancers in older women and 25-30% of breast cancers in women age 40 to 49 will not be detected by a screening mammogram, physical examination by the family physician may improve early detection.

3.3 Screening Mammography

The policy of the Screening Mammography Program of BC reflects the latest evidence and our commitment to reducing breast cancer deaths by finding cancer at an early stage. Key policy recommendations are:

Average Risk, Ages 40-49 

Health care providers are encouraged to discuss the risks and benefits  of screening mammography with asymptomatic women in this age group. 

If screening mammography is chosen, patients will be recalled every two years. A health care provider’s referral is not required but is recommended.

Average Risk, Ages 50-74

Routine screening mammograms are recommended every two years for asymptomatic women at average risk of developing breast cancer. Patients will be recalled every two years. A health care provider’s referral is not required.

Average Risk, Ages 75+

Health care providers are encouraged to discuss the benefits and limitations of screening mammography with asymptomatic women in this age group.

Health care providers should discuss stopping screening when there are comorbidities associated with a limited life expectancy or physical limitations for mammography that prevent proper positioning.

If screening mammography is chosen, it is available every two to three years. Patients will not be recalled by the Screening Mammography Program of BC. A health care provider’s referral is not required but is recommended.

Higher than average risk, e.g. Ages 40-74 with a first degree relative with breast cancer

Routine screening mammograms are recommended every year. Patients will be recalled every year. A health care provider’s referral is not required.

High risk, with a known BRCA1 or BRCA2 mutation or prior chest wall radiation or strong family history of breast cancer

Age 40-74: Routine screening mammograms are recommended every year. Patients will be recalled every year. A health care provider’s referral is not required.

Under age 40: The Screening Mammography Program accepts women at high risk of developing breast cancer with a health care provider’s referral, provided they do not have breast implants or an indication for a diagnostic mammogram. Please discuss patient with a screening program radiologist before referral.

3.4 Magnetic Resonance Imaging (MRI)

Routine screening with breast MRI of women at average risk of developing breast cancer is not recommended.

Patients who are mutation carriers or from families with confirmed mutations are recommended to have annual screening breast MRI from age 25 to 65. Referral to the Hereditary Cancer Program can facilitate these arrangements. Women who have had chest radiation between 10 and 30 years of age are also recommended to have annual screening breast MRI alternating with annual mammograms, i.e. screening imaging every 6 months, starting the earlier of 10 years after radiation or the age of 40. 

More information about the utility of MRI in the screening and diagnosis in the setting of breast cancer is discussed in the Diagnosis section.

3.5 Other Methods

There has been considerable interest in methods of detection of non-palpable abnormalities in the breast that do not use ionizing radiation. Such methods include thermography, ultrasound and diaphanography, but in the screening of asymptomatic women none of these techniques approach the sensitivity or the specificity of mammography and cannot be recommended at the present time as the sole screening method. 

Ultrasound may be very useful, in conjunction with mammogram, for diagnosis of (to assess) breast lesions, and in that situation is part of the workup of a mass. However, in the absence of any abnormality on physical examination or mammogram, ultrasound is not required, is not a validated screening method, and is not funded.
 
Referral to Hereditary Cancer Program

The Hereditary Cancer Program is a joint activity of BC Cancer and the Provincial Medical Genetics Program. Testing is available for families at risk of mutations in breast cancer predisposition genes including, but not restricted to, BRCA1 or BRCA2. Women with gene mutations are candidates for programs of special surveillance.

Specific criteria for referral to the Hereditary Cancer Program are listed separately.

Referral should be offered to asymptomatic women with increased risk of hereditary breast cancer, including those with the following:

  • Family history of bilateral breast cancer
  • Family history of breast cancer at age <35 years
  • Multiple cases of close relatives with breast cancer
  • Family or personal history of ovarian cancer 
  • Family history of male breast cancer
  • Ashkenazi Jewish heritage

SOURCE: 3. Screening/Early Detection ( )
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