Breast Cancer Screening Guidelines

In case you haven't noticed the explosion of pink merchandise and memorabilia around you, October is National Breast Cancer Awareness Month.  As nurse practitioners, let's participate in the movement by reviewing breast cancer screening guidelines so we can make sure our patients are up-to-date in their preventative practices. 

Why is Breast Cancer Screening Important?

Given the success of the breast cancer awareness movement, it is easy to write it off as a marketing ploy for companies and an excuse to organize a 5k rather than an opportunity to raise awareness of a public health issue.   But, as healthcare providers we must not lose site of the importance of educating our patients about breast cancer and take advantage of this month to do so.  One in eight (!) women in the U.S. will develop breast cancer.  Breast cancer is the second leading cause of cancer deaths among women in the U.S. killing nearly 40,000 women in 2011.  The most significant risk factors for developing breast cancer, gender (being female) and age (growing older), are not preventable.  Therefore, we must teach women to be vigilant and follow breast cancer screening guidelines.

Breast Self Exam

The U.S. Preventative Services Task Force (USPSTF) recommends against teaching breast self-exam.  Research has shown that self-breast exam does not reduce a woman's risk of dying of cancer.  This change in recommendations is difficult for many clinicians to swallow.  Self breast exam does not cost anything to the individual or the healthcare system and poses no risk to the patient.  The American Cancer Society modifies this position stating that "women should know how their breasts normally look and feel and report any changes promptly to their healthcare provider".  The ACS recommends breast self-exam as an "option" for women starting in their 20's.

As a provider, you need to educate patients about changes they should look for should they choose to do self breast exam.  Examples of notable breast changes include swelling or warmth, dimpling or puckering of the skin and nipple discharge.  The Susan G. Komen website offers excellent resources to help with your patient education efforts. 

Clinical Breast Exam

Clinical breast exam, preformed by the healthcare provider most often in association with a routine preventative GYN visit, is recommended by the American Cancer Society every 3 years for women in their 20's and 30's and every year for women in their 40's.  The USPSTF believes their is insufficient evidence to evaluate the efficacy of the clinical breast exam and therefore does not make a recommendation concerning this screening tool.  

As healthcare providers, we should follow the guidelines set forth by the ACS until further evidence in support for or against clinical breast exam is evaluated. 

Mammography

The USPSTF recommends against screening mammogram in women under age 49.  The USPSTF does recommend women begin receiving screening mammograms every other year between the ages of 50 and 74.  The American Cancer Society, however suggests women receive annual mammograms beginning at the age of 40 continuing for as long as the woman is in good health.

As a healthcare provider, you must work with your patients to evaluate these differing guidelines and make a collaborative decision regarding screening in each patient personally.  Patients with a history of radiation exposure or a family history of breast cancer, especially in a first degree relative, should err more on the side of the guidelines of the ACS.  Patients with few external risk factors for breast cancer may wish to follow the more conservative USPSTF guidelines as mammograms are costly and do expose patients to radiation. 

MRI for Breast Cancer Screening

Fewer than 2% of women in the U.S. are at very high risk for developing breast cancer.  These women should have MRI screening for breast cancer as it is the most effective method of early detection.  The National Cancer Society has a breast cancer screening tool online that you can use to calculate breast cancer risk in your patients.  Women at high risk include those with the BRCA1 or BRCA2 gene mutation or those with a first degree relative who have these genetic mutations.  Women with a lifetime risk of breast cancer of 20% or greater should get an MRI in addition to a mammogram each year according to the National Cancer Society.  Women with a 15 to 20% risk should consider an annual breast cancer screening MRI in addition to mammography.  

Over the past ten years, breast cancer screening recommendations released by the government have become less rigorous.  Guidelines published by organizations such as the National Cancer Society and the American Cancer Society have remained more consistent.  Rather than simply adopting one set of guidelines over the other, discuss recommendations from various organizations with your patients, calculate their risk of developing breast cancer and create an individualized breast cancer prevention plan for your female patients.  This will empower them allowing them to take responsibility for their personal breast cancer preventative care based on their unique circumstances and preferences.