How often should women be screened for breast cancer?
MRI is more sensitive screening than mammography and the combination of MRI and routine mammograms is more sensitive than either test alone. In 2007, the ACS recommended annual breast MRI screening in addition to mammogram for women at high risk for breast cancer (Table 2). For women with moderately increased risk (15% to 20% lifetime) there is insufficient evidence to recommend for or against MRI for screening, but one may consider it on a case-by-case basis; for example, for women with personal history of breast cancer, atypical hyperplasia, or with mammographically dense breasts.
Table 2
American Cancer Society breast cancer screening recommendations
| Women at average risk* | Women at high risk* | |
|---|---|---|
| Breast self-exam | Not routinely recommended. Discuss the benefits and limitations starting with patients in their 20s. Emphasize the importance of reporting new breast symptoms to a health care provider | |
| Clinical breast exam | At least every 3 years for women in their 20s and 30s. Annually starting at age 40 | Annually, starting at age 30 |
| Mammography | Annually, starting at age 40 | Annually, starting at age 30 |
| Breast MRI | Not recommended | Annually, starting at age 30, along with mammogram |
| *Women at average risk for breast cancer include those with an estimated lifetime risk of <15%. Women with an estimated lifetime risk of 15% to 20% are at moderate risk. Women >20% are at high risk and should consider more intensive screening | ||
| Source: References 7,8, American Cancer Society (www.cancer.org) | ||
Potential harms
Potential mammography harms include the possibility of a false positive result, anxiety as one awaits the test result, and anticipation of discomfort associated with the procedure. There also is the potential for “overdiagnosis” or detection of a cancer that would not have adversely impacted the patient if it had not been discovered. There is also a small risk of radiation exposure from repeated mammograms, but this has not been firmly established in the literature.
False-positive results—an abnormal finding on mammogram that does not result in a breast cancer diagnosis—is a significant issue. One study estimated that 11% of screening mammograms return abnormal findings that lead to additional workup, the majority (90%) of which ultimately result in benign diagnoses.11 Workup often leads to additional mammograms, ultrasound, breast MRI, and invasive procedures such as needle biopsies. False-positive mammograms have been associated with increased symptoms of depression and anxiety.12 Patients may be more apprehensive about breast cancer following a false-positive result, but this does not appear to lead to chronic anxiety.13
The vulnerability of patients experiencing psychiatric illness coupled with the potential psychological consequences of breast cancer make it imperative that psychiatrists remain up-to-date on breast cancer screening guidelines. Reported poor adherence to screening recommendations for mammography may increase the burden of illness and mortality from breast cancer in individuals with mental illness.
Conversations about health maintenance measures always should include careful discussion of the benefits and potential harms associated with the recommended screening tools. Because psychiatrists work closely with patients who may be less likely to undergo mammography, it is important to provide support and advocate for access to health care screening.
Related Resource
- National Cancer Institute. www.cancer.gov.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Table 3
Number needed to screen (NNS) with mammography to prevent 1 breast cancer death
| Age | NNS |
|---|---|
| 39 to 49 | 1,904 |
| 50 to 59 | 1,339 |
| 60 to 69 | 337 |
| Source: Reference 9 | |
