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Comparing the Various Breast Cancer Screening Guidelines
The Journal for Nurse Practitioners xxx (xxxx) xxx
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Comparing the Various Breast Cancer Screening Guidelines Myriam Jean Cadet, PhD, FNP-C a b s t r a c t Keywords: breast cancer screening guidelines mammogram shared decision making
Breast cancer is the second leading cause of death among women; early detection has been shown to reduce morbidity and mortality risk. Nurse practitioners’ roles are to screen patients for early detection to provide safe care. This article compares the evidence-based screening guidelines for breast cancer. © 2019 Elsevier Inc. All rights reserved.
Breast cancer is the leading cause of premature mortality cancer among women in the United States.1 American Cancer Society (ACS) guidelines recommended screening for breast cancer using a mammography test. Early detection using a mammogram annually has been shown to improve breast cancer survival rates.1 A mammography screening is associated with a 19% reduction in breast cancer mortality rates.1,2 However, harms from screening are overdiagnosis and overtreatment, false-positive (absence of cancer) findings, and false-negative (missed cancer) findings.3,4 Ten years of performing annual mammograms among women aged 40 to 50 years revealed that the cumulative risk of false-positive findings was approximately 61%.2 Nurse practitioners (NPs) need to understand the screening recommendations for the early detection of breast cancer to offer informed decision making for safe screening options. This article compares the screening guidelines for breast cancer. Background It is estimated that 42,260 breast cancer deaths (41,760 women and 500 men) will occur in 2019.1 An estimated 2,670 men and 268,600 women are living with invasive breast cancer in the US.1 From 2006 to 2015, invasive breast cancer incidence among females increased by 0.4% each year.1 The risk for breast cancer increases with reproductive history, environmental factors, or genetic mutations.1,5 These risk factors need to be assessed because they are areas of controversy for screening. Misidentification of these risk factors may result in screening harms. Modifiable Risk Factors Elevated body mass index is a modifiable risk factor. A study discovered that postmenopausal women with high body fat levels are at higher risk of invasive breast cancer.6 A randomized https://doi.org/10.1016/j.nurpra.2019.03.022 1555-4155/© 2019 Elsevier Inc. All rights reserved.
controlled trial previously investigated a long-term dietary intervention on breast cancer incidence.7 Results supported a Mediterranean diet supplemented with extra-virgin olive oil for primary prevention of breast cancer. Likewise, physical inactivity has been thought to raise the risk of getting breast cancer,6 and increased physical activity may lower breast cancer risk.8 Nonmodifiable Risk Factors Age A nonmodifiable risk factor for breast cancer is female sex. The American College of Obstetricians and Gynecologists (ACOG) reported that 99% of breast cancer occurs in women. Another risk factor of getting breast cancer is age.1,3,9 Family History Women with a family history of breast cancer, ovarian cancer, prostate cancer, pancreatic cancer, and inherited mutations in BRCA1 and BRCA2 gene carriers are at higher risk of breast cancer.1 Additionally, women with BRCA1 and BRCA2 genes have inherited mutations. Those who are carriers account for up to 30% of inheritable breast cancer.10 Reproductive Risk Factors Nulliparity, early menarche, late menopause, long menstruation history, never conceiving, not breastfeeding, conceiving late at age 30, recent use of oral contraceptives, and use of menopausal hormone therapy (eg, estrogen and progestin) raise the risk of breast cancer.3 A prospective, longitudinal cohort study of BRCA1 and BRCA2 mutation carriers was conducted between 1995 and 2017 with women from 80 participating centers in 17 countries.11 The results suggested that after oophorectomy, the use of estrogen therapy did not increase the risk of breast cancer among women who were carriers of the BRCA1 mutation.11
2
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Breast Disorders and Breast Density Having a history of breast disorders was thought to increase the risk of breast cancer including atypical ductal hyperplasia, lobular carcinoma in situ, and atypical lobular hyperplasia.3 Women with high-density breast tissue are more likely to get breast cancer.1 Dense breast notification laws have been enacted in many states in the US to notify women of their risk of developing breast cancer. Failure to inform them about their risk or diagnosis is a potential source for malpractice.12 The state of Connecticut mandates insurance companies cover additional testing for women with dense breasts diagnosed by mammography screening.12 It is believed that additional tests such as ultrasounds and magnetic resonance imaging (MRI) may benefit these women to diagnose breast cancer.12
anxiety and lead to unnecessary biopsies.13 The American Academy of Family Physicians (AAFP) also does not advise practitioners to teach patients SBE. However, both organizations do recommend assessing patients’ screening values, screening preferences, and breast cancer risk factors; discussing a patient’s potential benefits of screening using an appropriate screening test; developing early detection plans; and minimizing potential screening harms. Although BSE is not recommended, ACOG guidelines recommended women practice breast self-awareness (eg, awareness of normal appearance and feel of the breast). This is important for NPs to be aware of, so they can counsel patients about signs and symptoms of breast cancer. Teach patients to report any redness, new onset of nipple discharge, mass, or pain.
Prediction Models Breast Cancer Risk Assessment Tool NPs need to consider a validated risk assessment tool to collect risk factors and health history. A well-known risk assessment tool, the Breast Cancer Risk Assessment Tool, is used to guide screening surveillance, genetic testing, and risk reduction. It assesses the risk of developing invasive breast cancer over the next 5 years and can be used with women up to age 90.13 The Breast Cancer Risk Assessment Tool has been validated to assess breast cancer risk among Hispanic, black, white, Asian, and Pacific Islander women in the US. However, there are some limitations for its use. It cannot accurately estimate breast cancer risk among women with breast cancereproducing mutations in BRCA1 (a women suppressor gene) or BRCA2 or women with a previous breast cancer history, invasive breast cancer, or breast cancer in situ (ductal carcinoma in situ or lobular carcinoma in situ).13 Other common validated tools are the Gail Model,14 a nongenetic risk assessment model, and genetic risk models including the BRCAPRO,15 Claus,16 and Tyrer-Cuzick17 models. All of these screening tools have limitations. For example, the Gail Model may underestimate risk in Hispanic women born outside the US and black women with previous biopsies.14 Other breast risk assessment tools can be retrieved from https://bcrisktool.cancer.gov/ about.html.
Clinical Breast Examination The consistency and external validity of clinical breast examination (CBE) is poor.13 It has not been shown to decrease mortality rates, and its efficacy for early detection of breast cancer is unclear. CBE may lead to additional testing, anxiety, false reassurance, and delay in cancer diagnosis.13 It was reported that 17% to 43% of women with breast cancer have a negative CBE.13 The US Preventive Services Task Force (USPSTF) guidelines do not recommend CBE based on the lack of a standardized and structured approach used by providers in performing this examination. However, the National Comprehensive Cancer Network (NCCN) does recommend CBE if BRCA is positive; it should begin at age 25. However, Provencher et al’s retrospective study20 supported the CBE tool for screening. The results revealed that of the 6,333 cancers, 54.8% (n ¼ 3,470) were discovered by mammography screening and CBE, 8.7% (n ¼ 551) were found by physicianperformed CBE alone (5.3% if considering ultrasonography), and 36.5% (n ¼ 2,312) were detected by mammography screening alone.20 The study concluded that if CBE was not performed, a significant number of cancers would have been missed. CBE is a low-cost test that may prompt further testing such as breast ultrasonography when a negative mammogram result is found.20
Breast Cancer Screening Modalities
Diagnostic Tests for Breast Cancer
There are different views on the screening modalities for breast cancer. In addition, guidelines differ on when to start or stop screening, benefits and harms of screening, and the issue of falsepositive and false-negative findings. Although screening can save lives, it can trigger unnecessary procedures including biopsies, testing recalls, mastectomies, systemic drug therapy, days off work, radiation, and debt related to health care costs.18 Medicare Accountable Care Organizations' roles are to prevent negative effects from breast cancer screening such as harms, overtreatment, and overdiagnosis.19 Similarly, Accountable Care Organizations advocate for quality care by offering incentives to providers to coordinate breast cancer screening. While these incentives were offered, some providers were concerned about reporting of poor performance ratings and the potential risk of medical malpractice.18
The USPSTF guidelines did not recommend using ultrasonography (USG) or MRI to screen for early detection of breast cancer. Mainstay imaging is mammography for screening. NPs can use USG or MRI tests as supplemental imaging to rule out a breast cancer diagnosis.
Self-breast Examination The National Institutes of Health does not recommend selfbreast examination (SBE) for early breast cancer detection because it does not decrease mortality rates. Evidence revealed that SBE external validity was poor, and it may increase a patient’s
Mammography Radiation-induced breast cancer, testing anxiety, and a potential delay in cancer diagnosis are concerns with mammogram screening. In the US, approximately 10% of women were recalled for further testing, and 0.5% of them were diagnosed with breast cancer.13 False-negative findings have been reported in 6% to 46% of mammograms.13 The National Institutes of Health reported that randomized controlled trials provided evidence that for women 50 to 69 years, a mammogram test may improve breast cancer survival rates. A mammogram screening is effective in reducing breast cancer mortality rates.21 NPs should know that some cancers may not be detectable when using mammogram screening, and further testing may be indicated.
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3
Table 1 Breast Cancer Screening Guidelines Screening Criteria
American Cancer Society (2015)
US Preventive Services Task Force (2016)
American College of Obstetricians and Gynecologist
American Academy of Family Physician (2016)
National Comprehensive Cancer Network (2015)
< 40 years
Individualize screening Shared decisions Yearly mammogram
Screening before aged 40 years should be individualized Aged 40 to 49 years; decisions to be screened should be individualized.
No recommendation
Not addressed
Not addressed
Aged 40 and 49 years biennial screening with mammogram
Aged 40 years start mammogram annually
Aged 50- 74 years
Mammogram yearly or biennial
Biennial screening women for breast cancer aged 50 to 74 years is recommended.
Recommendation for mammogram is every 2 years.
Not addressed
Aged 75 or older
Mammogram yearly or biennial
Aged 75 no recommendation
Average-risk women 40 years of age should be offered a mammogram and screened yearly or every 2 years. Recommend a mammogram if patient did not start screening by aged 50 years. Shared decision making after age 75.
Screening women age 75 years or older is not recommended.
Clinical breast examination
Does not recommend clinical breast examination
Insufficient evidence to recommend for or against
Stop mammogram when severe morbidities limit life expectancy for 10 years of less. Recommend annually for women 40 years and older.
Aged 40-49 years
May be offered for women age 40 and older annually and 1-3 years for women aged 25-39 years
Recommend clinical breast examination but does not recommend self-breast examination.
USG
ACS
A breast ultrasound distinguishes a solid mass, fluid cyst, or a benign cyst from breast cancer. A study found that the accuracy of USG was better than a mammogram.22 Besides, the study revealed that the sensitivity of USG was significantly higher than the sensitivity of mammography with a result of 75% versus 44%. However, USG specificity was lower than mammography with a result of 79% versus 91%.22 This test may be used in women with high-density breast tissue or abnormal findings from mammogram screening.
The ACS guidelines were developed based on a systematic review of randomized controlled trials in average-risk women and the use of mammograms for screening for early detection to decrease mortality.24 Additionally, the guidelines addressed questions related to screening intervals.
MRI MRI produces detailed pictures of a patient’s breast. It can detect high-grade ductal carcinoma in situ. A retrospective study discovered that an MRI test had higher cancer detection rates than a mammogram test with a sensitivity result of 92.3% versus 30.8%, but it had a lower specificity result of 85.9% versus 96.8%.23 The ACS guidelines recommend MRI for women at high risk such as those with a genetic mutation, an estimated lifetime risk of 20% to 25%, and a history of radiation of the chest at ages 10 to 30 years. NPs need to understand that MRI may be used as a supplementary test because its role in the early detection of breast cancer is not welldefined.
NCCN The NCCN convened a panel of 52 volunteer clinicians and researchers from many specialties to develop guidelines for breast cancer. They analyzed the results of meta-analyses of randomized controlled trials from the ACS guidelines.25 The recommendations are based on categories of scientific evidence and considerations given to interventions. USPSTF The USPSTF used systematic reviews to determine the frequency of screening in women 50 years and older. The USPSTF guidelines focused on the effectiveness of breast cancer screening. Also, they focused on test performance characteristics and adjunctive screening tests.26 ACOG
Breast Cancer Screening Guideline Recommendations Each organization uses different methodologies for evaluating the scientific evidence to develop its clinical guidelines for breast cancer screening, which can lead to conflicting recommendations. NPs need to be aware of this so they can explain to their patients when they discuss what recommendations to follow. A study found that more than a quarter of providers (26.0%) reported trusting the ACOG guidelines for breast cancer the most, 23.8% trusted the ACS guidelines, and 22.9% trusted the USPSTF guidelines.23 Table 1 compares the screening recommendations for breast cancer.
The ACOG guidelines focused on risk assessment, screening controversies, and screening recommendations. A framework of shared decision-making was proposed. It aids patients to make breast cancer screening decisions. AAFP The AAFP supports the USPSTF recommendations on breast cancer screening. They encouraged informed decision making and effective clinical judgment when screening patients to individualize care.27
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Table 2 Decision Aid Tools Women All Age Decision Aid
Website: Resources
Harding Center for Risk Literacy Fact Box: Early Detection of Breast Cancer by Mammography Screening Australian Decision Aid for Women Aged 40 Thinking about Starting Mammography Screening Videos Harvard Medical School Video: Mammography: How to Make the Right Decision for You Kaiser Health News Lazaris-Rifkin Breast Cancer Risk-Benefit Characterization Theatre
https://www.harding-center.mpg.de/en/fact-boxes/early-detection-of-cancer/ breast-cancer-early-detection http://www.mammogram.med.usyd.edu.au/
Implications for Practice Most guidelines do not recommend screening in patients younger than 40 and over 75 years old.1,26 Still, some providers were willing to screen beyond this interval. One study’s results revealed that 67% of providers recommended screening women aged 75 years or older, 88% for women aged 45 to 49 years, and 81% for women aged 40 to 44 years.23 NPs need to offer information about mammography screening that will empower patients to perform self-care and make decisions about their screening options.
Shared Decision-making Process Shared decision making is a process in which the provider and the patient work together to make decisions on screening tests to promote wellness, prevent or limit illness, and restore health. Also, it helps providers to assess a patient’s preferences and values related to screening. The shared decision-making process is an ethical responsibility for NPs during screening to promote health and to assist in screening choices. Using a shared decision-making process may be timeconsuming in an environment where providers have limited time with patients.28 However, the premise of patient-centered care should be in place no matter how much time the provider has with patients. Developing a plan to integrate shared decision making into a busy practice is important, and prioritizing which clinical decisions warrant the implementation of this process is crucial29 (Table 2). NPs must educate patients about the benefits (eg, early detection and decreasing the risk of dying) and harms (eg, callbacks and biopsy of a benign tumor) of screening by sharing accurate screening information, providing screening resources, and helping them to develop self-care behaviors to make their own choices.
Decision Aid Keating and Pace28 advocated for expanding the use of decision tools for patients at their homes or in office waiting rooms to improve the quality of data collection during the shared decisionmaking process. Screening women 75 years and older for breast cancer is not recommended, but offering shared decision making with decision aid (DA) to assess readiness and the level of motivation for mammography screening is important. A pilot study developed and evaluated DA on mammography screening for women aged 75 years and older.30 Findings from the study concluded that DA might improve older women’s knowledge about harms and benefits of a mammogram screening, leading to fewer of them making decisions to be screened.30 The study concluded that providing DA before office visits can improve patient-provider communication about screening. A DA plan is located in Table 3.
https://www.youtube.com/watch?v¼lTnw2CpeGN4&feature¼youtu.be https://www.youtube.com/watch?v¼UZlY6Q4m-MM
Screening Literacy Limited health literacy is a barrier to effective preventive health behaviors31 and has been found to be a reason for not screening for breast cancer. A study investigated the relationship of mammography screening and health literacy. The researchers concluded that having a low literacy level was a predictor of a not being screened with mammography.32 Patients who have sufficient health literacy can obtain, interpret, and understand the necessary health information and services to maintain good health.33 People with high health literacy are most likely to obtain information to change their negative health behaviors.31,33 When educating patients with low health literacy levels about mammography screening, NPs need to use clear and effective health communication techniques, employ patientcentered communication, and confirm understanding of information given for screening. Education NPs need to do more than just educate patients about breast cancer guidelines. They need to provide accurate screening information and resources to support patients’ choices (eg, mammography screening) and to decrease their anxiety levels. NPs’ roles are to bring awareness of mammography screening, educate on prevention and risk factors, and implement educational programs to reduce breast cancer incidence rates. Research Research needs to be completed on patients’ readiness, attitudes, and knowledge of breast cancer screening. Another area for research is to examine barriers related to mammography Table 3 Shared Decision Plan Assessment Focus screening on patient-centered care Complete family history and risk factors Complete a physical examination Use a risk assessment tool Assess level of interest Assess for health literacy Assess specific needs and preferences Assess values Discussion Discuss about guidelines/recommendations Discuss benefits of screening with mammogram Explain harms related to mammogram Provide decisions aids to make informed decisions Discuss about the risk assessment tool results Decisions Focus screening on patients’ decisions, values, and preferences Document needs and choices
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screening adherence. More research is also needed on patient factors that may influence screening for breast cancer. Conclusion NPs need to understand all screening guideline recommendations and the differences between them to aid their patients in making informed decisions. Given the NPs’ influence in primary care settings, they need to develop effective breast cancer screening strategies and shared decision-making practices to educate and support patients’ decisions. References 1. American Cancer Society. https://www.cancer.org/content/dam/cancer-org/ research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/ cancer-facts-and-figures-2019.pdf. 2019. Accessed December 2, 2018. 2. Pace LE, Keating NL. A systematic assessment of benefits and risks to guide breast cancer screening decisions. JAMA. 2014;311(13):1327-1335. 3. American College of Gynecologists and Obstetricians. Breast cancer risk assessment and screening in average-risk women. https://www.acog.org/-/ media/Practice-Bulletins/Committee-on-Practice-Bulletins——Gynecology/Public/ pb179.pdf?dmc¼1&ts¼20181223T1316205592. 2017. Accessed December 3, 2018. 4. Baron R, Drucker K, Lagdamen L, Cannon M, Mancini C, Fischer-Cartlidge E. C.E: breast cancer screening: a review of current guidelines. Am J Nurs. 2018;118(7):34-41. 5. Shah R, Rosso K, Nathanson SD. Pathogenesis, prevention, diagnosis and treatment of breast cancer. World J Clin Oncol. 2014;5(3):283-298. 6. Iyengar NM, Arthur R, Manson JE, et al. Association of body fat and risk of breast cancer in postmenopausal women with normal body mass index: a secondary analysis of a randomized clinical trial and observational study. JAMA Oncol. 2018 Dec 6 [Epub ahead of print]. J, Donat-Vargas C, et al. Mediterranean diet and 7. Toledo E, Salas-Salvado invasive breast cancer risk among women at high cardiovascular risk in the PREDIMED trial: a randomized clinical trial. JAMA Intern Med. 2015;175(11): 1752-1760. 8. Moore SC, Lee IM, Weiderpass E, et al. Association of leisure-time physical activity with risk of 26 types of cancer in 1.44 million adults. JAMA Intern Med. 2016;176(6):816-825. 9. Walter LC, Schonberg MA. Screening mammography in older women: a review. JAMA. 2014;311(13):1336-1347. 10. Valencia OM, Samuel SE, Viscusi RK, Riall TS, Neumayer LA, Aziz H. The role of genetic testing in patients with breast cancer: a review. JAMA Surg. 2017;152(6):589-594. 11. Kotsopoulos J, Gronwald J, Karlan BY, et al. Hormone replacement therapy after oophorectomy and breast cancer risk among BRCA1 mutation carriers. JAMA Oncol. 2018;4(8):1059-1065. 12. Haas JS, Kaplan CP. The divide between breast density notification laws and evidence-based guidelines for breast cancer screening: legislating practice. JAMA Intern Med. 2015;175(9):1439-1440. 13. National Institute of Health. Breast cancer screening health professional version. https://www.cancer.gov/types/breast/hp/breast-screening-pdq#link/_ 33_toc. 2018. Accessed January 4, 2019. 14. Gail MH, Brinton LA, Byar DP, et al. Projecting individualized probabilities of developing breast cancer for white females who are being examined annually.
15.
16. 17. 18. 19. 20.
21. 22.
23.
24.
25.
26.
27.
28. 29. 30.
31.
32.
33.
5
J Natl Cancer Inst. 1989;81:1879-1886. https://doi.org/10.1093/jnci/ 81.24.1879. Parmigiani G, Berry DA, Aquilar O. Determining carrier probabilities for breast cancer susceptibility genes BRCA1 and BRCA2. Am J Hum Genet. 1998;62: 145-148. https://doi.org/10.1086/301670. Claus EB, Risch N, Thompson WD. Genetic analysis of breast cancer in the cancer and steroid hormone study. Am J Hum Genet. 1991;48:232-242. Tyrer J, Duffy SW, Cuzick J. A breast cancer prediction model incorporating familial and personal risk factors. Stat Med. 2004;23:1111-1130. Elmore JG, Kramer BS. Breast cancer screening: toward informed decisions. JAMA. 2014;311(13):1298-1299. Lipitz-Snyderman A. Accountability for underuse and overuse of cancer screening. JAMA Intern Med. 2018;178(5):655-656. Provencher L, Hogue JC, Desbiens C, et al. Is clinical breast examination important for breast cancer detection? Curr Oncol. 2016;23(4):e332-e339. Chetlen A, Mack J, Chan T. Breast cancer screening controversies: who, when, why, and how? Clin Imaging. 2016;40(2):279-282. Tan KP, Mohamad ZA, Rumaisa MP, et al. The comparative accuracy of ultrasound and mammography in the detection of breast cancer. Med J Malaysia. 2014;69(2):79-85. Radhakrishnan A, Nowak SA, Parker AM, Visvanathan K, Pollack CE. Physician breast cancer screening recommendations following guideline changes: results of a national survey. JAMA Intern Med. 2017;177(6):877-878. Oeffinger KC, Fontham ET, Etzioni R, et al. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 2015;314(15):1599-1614. National Comprehensive Cancer Network. NCCN guidelines version 1. 2015 breast cancer screening and diagnosis. http://www.consensocancermamario. com/guias/NCCN_Pesquisa_y_Diagnostico_2015.pdf. 2015. Accessed January 6, 2019. US Preventive Service Task Force. https://www.uspreventiveservicestaskforce. org/Page/Document/RecommendationStatementFinal/breast-cancer-screening1. 2016. Accessed January 6, 2019. American Academy of Family Physicians. Summary of recommendations of clinical preventives services. https://www.aafp.org/dam/AAFP/documents/patient_care/ clinical_recommendations/cps-recommendations.pdf. 2016. Accessed January 6, 2019. Keating NL, Pace LE. Breast cancer screening in 2018: time for shared decision making. JAMA. 2018;319(17):1814-1815. Kuppermann M, Sawaya GF. Shared decision-making: easy to evoke, challenging to implement. JAMA Intern Med. 2015;175(2):167-168. Schonberg MA, Hamel MB, Davis RB, et al. Development and evaluation of a decision aid on mammography screening for women 75 years and older. JAMA Intern Med. 2014;174(3):417-424. Han HR, Huh B, Kim MT, Kim J, Nguyen T. Development and validation of the assessment of health literacy in breast and cervical cancer screening. J Health Commun. 2014;19(suppl 2):267-284. Komenaka IK, Nodora JN, Hsu CH. Association of health literacy with adherence to screening mammography guidelines. Obstet Gynecol. 2015;125(4): 852-859. Nutbeam D. Health promotion glossary, World Health Organization (WHO). Great Britain: Oxford University Press; 2014; WHO/HPR/HEP/98.1.
Myriam Jean Cadet, PhD, FNP-C, is an adjunct assistant professor at Lehman College in Bronx, NY. She can be contacted at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Comparing the Various Breast Cancer Screening Guidelines Myriam Jean Cadet, PhD, FNP-C a b s t r a c t Keywords: breast cancer screening guidelines mammogram shared decision making
Breast cancer is the second leading cause of death among women; early detection has been shown to reduce morbidity and mortality risk. Nurse practitioners’ roles are to screen patients for early detection to provide safe care. This article compares the evidence-based screening guidelines for breast cancer. © 2019 Elsevier Inc. All rights reserved.
Breast cancer is the leading cause of premature mortality cancer among women in the United States.1 American Cancer Society (ACS) guidelines recommended screening for breast cancer using a mammography test. Early detection using a mammogram annually has been shown to improve breast cancer survival rates.1 A mammography screening is associated with a 19% reduction in breast cancer mortality rates.1,2 However, harms from screening are overdiagnosis and overtreatment, false-positive (absence of cancer) findings, and false-negative (missed cancer) findings.3,4 Ten years of performing annual mammograms among women aged 40 to 50 years revealed that the cumulative risk of false-positive findings was approximately 61%.2 Nurse practitioners (NPs) need to understand the screening recommendations for the early detection of breast cancer to offer informed decision making for safe screening options. This article compares the screening guidelines for breast cancer. Background It is estimated that 42,260 breast cancer deaths (41,760 women and 500 men) will occur in 2019.1 An estimated 2,670 men and 268,600 women are living with invasive breast cancer in the US.1 From 2006 to 2015, invasive breast cancer incidence among females increased by 0.4% each year.1 The risk for breast cancer increases with reproductive history, environmental factors, or genetic mutations.1,5 These risk factors need to be assessed because they are areas of controversy for screening. Misidentification of these risk factors may result in screening harms. Modifiable Risk Factors Elevated body mass index is a modifiable risk factor. A study discovered that postmenopausal women with high body fat levels are at higher risk of invasive breast cancer.6 A randomized https://doi.org/10.1016/j.nurpra.2019.03.022 1555-4155/© 2019 Elsevier Inc. All rights reserved.
controlled trial previously investigated a long-term dietary intervention on breast cancer incidence.7 Results supported a Mediterranean diet supplemented with extra-virgin olive oil for primary prevention of breast cancer. Likewise, physical inactivity has been thought to raise the risk of getting breast cancer,6 and increased physical activity may lower breast cancer risk.8 Nonmodifiable Risk Factors Age A nonmodifiable risk factor for breast cancer is female sex. The American College of Obstetricians and Gynecologists (ACOG) reported that 99% of breast cancer occurs in women. Another risk factor of getting breast cancer is age.1,3,9 Family History Women with a family history of breast cancer, ovarian cancer, prostate cancer, pancreatic cancer, and inherited mutations in BRCA1 and BRCA2 gene carriers are at higher risk of breast cancer.1 Additionally, women with BRCA1 and BRCA2 genes have inherited mutations. Those who are carriers account for up to 30% of inheritable breast cancer.10 Reproductive Risk Factors Nulliparity, early menarche, late menopause, long menstruation history, never conceiving, not breastfeeding, conceiving late at age 30, recent use of oral contraceptives, and use of menopausal hormone therapy (eg, estrogen and progestin) raise the risk of breast cancer.3 A prospective, longitudinal cohort study of BRCA1 and BRCA2 mutation carriers was conducted between 1995 and 2017 with women from 80 participating centers in 17 countries.11 The results suggested that after oophorectomy, the use of estrogen therapy did not increase the risk of breast cancer among women who were carriers of the BRCA1 mutation.11
2
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Breast Disorders and Breast Density Having a history of breast disorders was thought to increase the risk of breast cancer including atypical ductal hyperplasia, lobular carcinoma in situ, and atypical lobular hyperplasia.3 Women with high-density breast tissue are more likely to get breast cancer.1 Dense breast notification laws have been enacted in many states in the US to notify women of their risk of developing breast cancer. Failure to inform them about their risk or diagnosis is a potential source for malpractice.12 The state of Connecticut mandates insurance companies cover additional testing for women with dense breasts diagnosed by mammography screening.12 It is believed that additional tests such as ultrasounds and magnetic resonance imaging (MRI) may benefit these women to diagnose breast cancer.12
anxiety and lead to unnecessary biopsies.13 The American Academy of Family Physicians (AAFP) also does not advise practitioners to teach patients SBE. However, both organizations do recommend assessing patients’ screening values, screening preferences, and breast cancer risk factors; discussing a patient’s potential benefits of screening using an appropriate screening test; developing early detection plans; and minimizing potential screening harms. Although BSE is not recommended, ACOG guidelines recommended women practice breast self-awareness (eg, awareness of normal appearance and feel of the breast). This is important for NPs to be aware of, so they can counsel patients about signs and symptoms of breast cancer. Teach patients to report any redness, new onset of nipple discharge, mass, or pain.
Prediction Models Breast Cancer Risk Assessment Tool NPs need to consider a validated risk assessment tool to collect risk factors and health history. A well-known risk assessment tool, the Breast Cancer Risk Assessment Tool, is used to guide screening surveillance, genetic testing, and risk reduction. It assesses the risk of developing invasive breast cancer over the next 5 years and can be used with women up to age 90.13 The Breast Cancer Risk Assessment Tool has been validated to assess breast cancer risk among Hispanic, black, white, Asian, and Pacific Islander women in the US. However, there are some limitations for its use. It cannot accurately estimate breast cancer risk among women with breast cancereproducing mutations in BRCA1 (a women suppressor gene) or BRCA2 or women with a previous breast cancer history, invasive breast cancer, or breast cancer in situ (ductal carcinoma in situ or lobular carcinoma in situ).13 Other common validated tools are the Gail Model,14 a nongenetic risk assessment model, and genetic risk models including the BRCAPRO,15 Claus,16 and Tyrer-Cuzick17 models. All of these screening tools have limitations. For example, the Gail Model may underestimate risk in Hispanic women born outside the US and black women with previous biopsies.14 Other breast risk assessment tools can be retrieved from https://bcrisktool.cancer.gov/ about.html.
Clinical Breast Examination The consistency and external validity of clinical breast examination (CBE) is poor.13 It has not been shown to decrease mortality rates, and its efficacy for early detection of breast cancer is unclear. CBE may lead to additional testing, anxiety, false reassurance, and delay in cancer diagnosis.13 It was reported that 17% to 43% of women with breast cancer have a negative CBE.13 The US Preventive Services Task Force (USPSTF) guidelines do not recommend CBE based on the lack of a standardized and structured approach used by providers in performing this examination. However, the National Comprehensive Cancer Network (NCCN) does recommend CBE if BRCA is positive; it should begin at age 25. However, Provencher et al’s retrospective study20 supported the CBE tool for screening. The results revealed that of the 6,333 cancers, 54.8% (n ¼ 3,470) were discovered by mammography screening and CBE, 8.7% (n ¼ 551) were found by physicianperformed CBE alone (5.3% if considering ultrasonography), and 36.5% (n ¼ 2,312) were detected by mammography screening alone.20 The study concluded that if CBE was not performed, a significant number of cancers would have been missed. CBE is a low-cost test that may prompt further testing such as breast ultrasonography when a negative mammogram result is found.20
Breast Cancer Screening Modalities
Diagnostic Tests for Breast Cancer
There are different views on the screening modalities for breast cancer. In addition, guidelines differ on when to start or stop screening, benefits and harms of screening, and the issue of falsepositive and false-negative findings. Although screening can save lives, it can trigger unnecessary procedures including biopsies, testing recalls, mastectomies, systemic drug therapy, days off work, radiation, and debt related to health care costs.18 Medicare Accountable Care Organizations' roles are to prevent negative effects from breast cancer screening such as harms, overtreatment, and overdiagnosis.19 Similarly, Accountable Care Organizations advocate for quality care by offering incentives to providers to coordinate breast cancer screening. While these incentives were offered, some providers were concerned about reporting of poor performance ratings and the potential risk of medical malpractice.18
The USPSTF guidelines did not recommend using ultrasonography (USG) or MRI to screen for early detection of breast cancer. Mainstay imaging is mammography for screening. NPs can use USG or MRI tests as supplemental imaging to rule out a breast cancer diagnosis.
Self-breast Examination The National Institutes of Health does not recommend selfbreast examination (SBE) for early breast cancer detection because it does not decrease mortality rates. Evidence revealed that SBE external validity was poor, and it may increase a patient’s
Mammography Radiation-induced breast cancer, testing anxiety, and a potential delay in cancer diagnosis are concerns with mammogram screening. In the US, approximately 10% of women were recalled for further testing, and 0.5% of them were diagnosed with breast cancer.13 False-negative findings have been reported in 6% to 46% of mammograms.13 The National Institutes of Health reported that randomized controlled trials provided evidence that for women 50 to 69 years, a mammogram test may improve breast cancer survival rates. A mammogram screening is effective in reducing breast cancer mortality rates.21 NPs should know that some cancers may not be detectable when using mammogram screening, and further testing may be indicated.
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Table 1 Breast Cancer Screening Guidelines Screening Criteria
American Cancer Society (2015)
US Preventive Services Task Force (2016)
American College of Obstetricians and Gynecologist
American Academy of Family Physician (2016)
National Comprehensive Cancer Network (2015)
< 40 years
Individualize screening Shared decisions Yearly mammogram
Screening before aged 40 years should be individualized Aged 40 to 49 years; decisions to be screened should be individualized.
No recommendation
Not addressed
Not addressed
Aged 40 and 49 years biennial screening with mammogram
Aged 40 years start mammogram annually
Aged 50- 74 years
Mammogram yearly or biennial
Biennial screening women for breast cancer aged 50 to 74 years is recommended.
Recommendation for mammogram is every 2 years.
Not addressed
Aged 75 or older
Mammogram yearly or biennial
Aged 75 no recommendation
Average-risk women 40 years of age should be offered a mammogram and screened yearly or every 2 years. Recommend a mammogram if patient did not start screening by aged 50 years. Shared decision making after age 75.
Screening women age 75 years or older is not recommended.
Clinical breast examination
Does not recommend clinical breast examination
Insufficient evidence to recommend for or against
Stop mammogram when severe morbidities limit life expectancy for 10 years of less. Recommend annually for women 40 years and older.
Aged 40-49 years
May be offered for women age 40 and older annually and 1-3 years for women aged 25-39 years
Recommend clinical breast examination but does not recommend self-breast examination.
USG
ACS
A breast ultrasound distinguishes a solid mass, fluid cyst, or a benign cyst from breast cancer. A study found that the accuracy of USG was better than a mammogram.22 Besides, the study revealed that the sensitivity of USG was significantly higher than the sensitivity of mammography with a result of 75% versus 44%. However, USG specificity was lower than mammography with a result of 79% versus 91%.22 This test may be used in women with high-density breast tissue or abnormal findings from mammogram screening.
The ACS guidelines were developed based on a systematic review of randomized controlled trials in average-risk women and the use of mammograms for screening for early detection to decrease mortality.24 Additionally, the guidelines addressed questions related to screening intervals.
MRI MRI produces detailed pictures of a patient’s breast. It can detect high-grade ductal carcinoma in situ. A retrospective study discovered that an MRI test had higher cancer detection rates than a mammogram test with a sensitivity result of 92.3% versus 30.8%, but it had a lower specificity result of 85.9% versus 96.8%.23 The ACS guidelines recommend MRI for women at high risk such as those with a genetic mutation, an estimated lifetime risk of 20% to 25%, and a history of radiation of the chest at ages 10 to 30 years. NPs need to understand that MRI may be used as a supplementary test because its role in the early detection of breast cancer is not welldefined.
NCCN The NCCN convened a panel of 52 volunteer clinicians and researchers from many specialties to develop guidelines for breast cancer. They analyzed the results of meta-analyses of randomized controlled trials from the ACS guidelines.25 The recommendations are based on categories of scientific evidence and considerations given to interventions. USPSTF The USPSTF used systematic reviews to determine the frequency of screening in women 50 years and older. The USPSTF guidelines focused on the effectiveness of breast cancer screening. Also, they focused on test performance characteristics and adjunctive screening tests.26 ACOG
Breast Cancer Screening Guideline Recommendations Each organization uses different methodologies for evaluating the scientific evidence to develop its clinical guidelines for breast cancer screening, which can lead to conflicting recommendations. NPs need to be aware of this so they can explain to their patients when they discuss what recommendations to follow. A study found that more than a quarter of providers (26.0%) reported trusting the ACOG guidelines for breast cancer the most, 23.8% trusted the ACS guidelines, and 22.9% trusted the USPSTF guidelines.23 Table 1 compares the screening recommendations for breast cancer.
The ACOG guidelines focused on risk assessment, screening controversies, and screening recommendations. A framework of shared decision-making was proposed. It aids patients to make breast cancer screening decisions. AAFP The AAFP supports the USPSTF recommendations on breast cancer screening. They encouraged informed decision making and effective clinical judgment when screening patients to individualize care.27
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Table 2 Decision Aid Tools Women All Age Decision Aid
Website: Resources
Harding Center for Risk Literacy Fact Box: Early Detection of Breast Cancer by Mammography Screening Australian Decision Aid for Women Aged 40 Thinking about Starting Mammography Screening Videos Harvard Medical School Video: Mammography: How to Make the Right Decision for You Kaiser Health News Lazaris-Rifkin Breast Cancer Risk-Benefit Characterization Theatre
https://www.harding-center.mpg.de/en/fact-boxes/early-detection-of-cancer/ breast-cancer-early-detection http://www.mammogram.med.usyd.edu.au/
Implications for Practice Most guidelines do not recommend screening in patients younger than 40 and over 75 years old.1,26 Still, some providers were willing to screen beyond this interval. One study’s results revealed that 67% of providers recommended screening women aged 75 years or older, 88% for women aged 45 to 49 years, and 81% for women aged 40 to 44 years.23 NPs need to offer information about mammography screening that will empower patients to perform self-care and make decisions about their screening options.
Shared Decision-making Process Shared decision making is a process in which the provider and the patient work together to make decisions on screening tests to promote wellness, prevent or limit illness, and restore health. Also, it helps providers to assess a patient’s preferences and values related to screening. The shared decision-making process is an ethical responsibility for NPs during screening to promote health and to assist in screening choices. Using a shared decision-making process may be timeconsuming in an environment where providers have limited time with patients.28 However, the premise of patient-centered care should be in place no matter how much time the provider has with patients. Developing a plan to integrate shared decision making into a busy practice is important, and prioritizing which clinical decisions warrant the implementation of this process is crucial29 (Table 2). NPs must educate patients about the benefits (eg, early detection and decreasing the risk of dying) and harms (eg, callbacks and biopsy of a benign tumor) of screening by sharing accurate screening information, providing screening resources, and helping them to develop self-care behaviors to make their own choices.
Decision Aid Keating and Pace28 advocated for expanding the use of decision tools for patients at their homes or in office waiting rooms to improve the quality of data collection during the shared decisionmaking process. Screening women 75 years and older for breast cancer is not recommended, but offering shared decision making with decision aid (DA) to assess readiness and the level of motivation for mammography screening is important. A pilot study developed and evaluated DA on mammography screening for women aged 75 years and older.30 Findings from the study concluded that DA might improve older women’s knowledge about harms and benefits of a mammogram screening, leading to fewer of them making decisions to be screened.30 The study concluded that providing DA before office visits can improve patient-provider communication about screening. A DA plan is located in Table 3.
https://www.youtube.com/watch?v¼lTnw2CpeGN4&feature¼youtu.be https://www.youtube.com/watch?v¼UZlY6Q4m-MM
Screening Literacy Limited health literacy is a barrier to effective preventive health behaviors31 and has been found to be a reason for not screening for breast cancer. A study investigated the relationship of mammography screening and health literacy. The researchers concluded that having a low literacy level was a predictor of a not being screened with mammography.32 Patients who have sufficient health literacy can obtain, interpret, and understand the necessary health information and services to maintain good health.33 People with high health literacy are most likely to obtain information to change their negative health behaviors.31,33 When educating patients with low health literacy levels about mammography screening, NPs need to use clear and effective health communication techniques, employ patientcentered communication, and confirm understanding of information given for screening. Education NPs need to do more than just educate patients about breast cancer guidelines. They need to provide accurate screening information and resources to support patients’ choices (eg, mammography screening) and to decrease their anxiety levels. NPs’ roles are to bring awareness of mammography screening, educate on prevention and risk factors, and implement educational programs to reduce breast cancer incidence rates. Research Research needs to be completed on patients’ readiness, attitudes, and knowledge of breast cancer screening. Another area for research is to examine barriers related to mammography Table 3 Shared Decision Plan Assessment Focus screening on patient-centered care Complete family history and risk factors Complete a physical examination Use a risk assessment tool Assess level of interest Assess for health literacy Assess specific needs and preferences Assess values Discussion Discuss about guidelines/recommendations Discuss benefits of screening with mammogram Explain harms related to mammogram Provide decisions aids to make informed decisions Discuss about the risk assessment tool results Decisions Focus screening on patients’ decisions, values, and preferences Document needs and choices
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screening adherence. More research is also needed on patient factors that may influence screening for breast cancer. Conclusion NPs need to understand all screening guideline recommendations and the differences between them to aid their patients in making informed decisions. Given the NPs’ influence in primary care settings, they need to develop effective breast cancer screening strategies and shared decision-making practices to educate and support patients’ decisions. References 1. American Cancer Society. https://www.cancer.org/content/dam/cancer-org/ research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/ cancer-facts-and-figures-2019.pdf. 2019. Accessed December 2, 2018. 2. Pace LE, Keating NL. A systematic assessment of benefits and risks to guide breast cancer screening decisions. JAMA. 2014;311(13):1327-1335. 3. American College of Gynecologists and Obstetricians. Breast cancer risk assessment and screening in average-risk women. https://www.acog.org/-/ media/Practice-Bulletins/Committee-on-Practice-Bulletins——Gynecology/Public/ pb179.pdf?dmc¼1&ts¼20181223T1316205592. 2017. Accessed December 3, 2018. 4. Baron R, Drucker K, Lagdamen L, Cannon M, Mancini C, Fischer-Cartlidge E. C.E: breast cancer screening: a review of current guidelines. Am J Nurs. 2018;118(7):34-41. 5. Shah R, Rosso K, Nathanson SD. Pathogenesis, prevention, diagnosis and treatment of breast cancer. World J Clin Oncol. 2014;5(3):283-298. 6. Iyengar NM, Arthur R, Manson JE, et al. Association of body fat and risk of breast cancer in postmenopausal women with normal body mass index: a secondary analysis of a randomized clinical trial and observational study. JAMA Oncol. 2018 Dec 6 [Epub ahead of print]. J, Donat-Vargas C, et al. Mediterranean diet and 7. Toledo E, Salas-Salvado invasive breast cancer risk among women at high cardiovascular risk in the PREDIMED trial: a randomized clinical trial. JAMA Intern Med. 2015;175(11): 1752-1760. 8. Moore SC, Lee IM, Weiderpass E, et al. Association of leisure-time physical activity with risk of 26 types of cancer in 1.44 million adults. JAMA Intern Med. 2016;176(6):816-825. 9. Walter LC, Schonberg MA. Screening mammography in older women: a review. JAMA. 2014;311(13):1336-1347. 10. Valencia OM, Samuel SE, Viscusi RK, Riall TS, Neumayer LA, Aziz H. The role of genetic testing in patients with breast cancer: a review. JAMA Surg. 2017;152(6):589-594. 11. Kotsopoulos J, Gronwald J, Karlan BY, et al. Hormone replacement therapy after oophorectomy and breast cancer risk among BRCA1 mutation carriers. JAMA Oncol. 2018;4(8):1059-1065. 12. Haas JS, Kaplan CP. The divide between breast density notification laws and evidence-based guidelines for breast cancer screening: legislating practice. JAMA Intern Med. 2015;175(9):1439-1440. 13. National Institute of Health. Breast cancer screening health professional version. https://www.cancer.gov/types/breast/hp/breast-screening-pdq#link/_ 33_toc. 2018. Accessed January 4, 2019. 14. Gail MH, Brinton LA, Byar DP, et al. Projecting individualized probabilities of developing breast cancer for white females who are being examined annually.
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Myriam Jean Cadet, PhD, FNP-C, is an adjunct assistant professor at Lehman College in Bronx, NY. She can be contacted at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.