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APPENDIX B 142 Independence Mall West, Sixth Street at Race, Philadelphia, PA 19106-1572, Tel 215-351-2400 American College of Physicians SCREENING FOR BREAST CANCER Clinical Efficacy Assessment Project Disease: The majority of breast cancers are infiltrating ductal carcinomas; the remainder are of various pathologic types. Although prognosis varies slightly with pathologic type, the principles of screening and management do not differ. Risk factors for breast cancer include socioeconomic factors, personal or family history, marital status, multiparity, age at first pregnancy, age at menarche and menopause, history of benign breast conditions, and diet. Screening test(s): Two main tests are used for breast cancer screening: breast physical examination and mammography. A breast physical examination performed by a trained practitioner entails visual inspection and manual palpation of the breast. Two types of mammography are used for breast cancer screening: plain-film and xeromammography. Xeromammography is effective in identifying microcalcifications associated with early breast cancers; plain-film mammography is more effective at detecting poorly defined lesions. Recommendations: 1. Screening with breast physical examination is recommended annually for asymptomatic women age 40 and older. 2. Screening with breast physical examination and mammography is recommended annually for asymptomatic women age 50 and older. 3. Screening with breast physical examination and mammography is recommended annually for women at any age who have a personal history of breast cancer. 4. Screening with breast physical examination and mammography is recommended annually for women age 40 or older who have a family history of breast cancer or who are otherwise at increased risk. Rationale: There is substantial direct evidence that breast cancer screening with breast physical examination and mammography reduces mortality from breast cancer in women over the age of 50. The evidence of effectiveness of mammography for women under age 50 is conflicting; however, the natural history of breast cancer in women under age 50 is such that annual screening with mammography in women who are at increased risk is strongly recommended. All women should be counselled regarding the benefits, risks and costs so they might choose the screening strategy that suits their personal history and preferences. The risks associated with breast cancer screening are primarily due to false- positive results which can lead to further diagnostic tests, including breast biopsy. Although radiation might increase the risk of a new cancer, the carcinogenic effect of the radiation from mammography is extremely small. Board of Regents Approved 4/10/89
