JavaScript has to be enabled to view this site. Learn how to enable JavaScript.

ICSI Icon

Level I – Breast Cancer Screening

Level I Services: Preventive services for which clinicians and health systems must assess the need. These services must be recommended to each patient, as they have the highest value and are worthy of attention at every opportunity.

The USPSTF recommendations are fully endorsed by the ICSI Preventive Services work group with qualifications:
Grade of Recommendation and Level of Certainty as Evaluated by USPSTF
  1. “Biennial screening mammography for women ages 50 to 74 years.”
  2. “The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.”
  3. “That the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women age 75 years or older.”
  4. “Against teaching breast self-examination (BSE).”
  5. “That the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women age 40 years or older.”
  6. “That the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.”
(USPSTF Last Revised 2009 – Update in Progress)
Grade of Recommendation:
  1. B
  2. C
  3. I Statement
  4. D
  5. I Statement
  6. I Statement

Level of Certainty:

  1. Moderate
  2. Moderate
  3. Insufficient
  4. Moderate
  5. Insufficient
  6. Insufficient
“Benefits:
There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women ages 50 to 74 years than for women ages 40 to 49 years. The strongest evidence for the greatest benefit is among women ages 60 to 69 years. Among women age 75 years or older, evidence of benefits of mammography is lacking. Adequate evidence suggests that teaching BSE does not reduce breast cancer mortality. The evidence for additional effects of CBE beyond mammography on breast cancer mortality is inadequate. The evidence for benefits of digital mammography and MRI of the breast, as a substitute for film mammography, is also lacking.
Harms:
The harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results. Furthermore, one must also consider the harms associated with treatment of cancer that would not become clinically apparent during a woman's lifetime (over-diagnosis), as well as the harms of unnecessary earlier treatment of breast cancer that would have become clinically apparent but would not have shortened a woman's life. Radiation exposure (from radiologic tests), although a minor concern, is also a consideration.
Adequate evidence suggests that the overall harms associated with mammography are moderate for every age group considered, although the main components of the harms shift over time. Although false-positive test results, over-diagnosis and unnecessary earlier treatment are problems for all age groups, false-positive results are more common for women ages 40 to 49 years, whereas over-diagnosis is a greater concern for women in the older age groups.
There is adequate evidence that teaching BSE is associated with harms that are at least small. There is inadequate evidence concerning harms of CBE.
Benefits-Harms Assessment:
For biennial screening mammography in women ages 40 to 49 years, there is moderate certainty that the net benefit is small. Although the USPSTF recognizes that the benefit of screening seems equivalent for women ages 40 to 49 years and 50 to 59 years, the incidence of breast cancer and the consequences differ. The USPSTF emphasizes the adverse consequences for most women – who will not develop breast cancer – and therefore use the number needed to screen to save one life as its metric. By this metric, the USPSTF concludes that there is moderate evidence that the net benefit is small for women ages 40 to 49 years.
For biennial screening mammography in women ages 50 to 74 years, there is moderate certainty that the net benefit is moderate.
For screening mammography in women 75 years or older, evidence is lacking, and the balance of benefits and harms cannot be determined.
For the teaching of BSE, there is moderate certainty that the harms outweigh the benefits.
For CBE as a supplement to mammography, evidence is lacking, and the balance of benefits and harms cannot be determined.
For digital mammography and MRI as a replacement for mammography, the evidence is lacking, and the balance of benefits and harms cannot be determined.”
Relevant Resources:
http://www.uspreventiveservicestaskforce.org/uspstf09/breastcancer/brcanrs.htm
ICSI Preventive Service Work Group Qualifications:
Counseling messages for effective shared decision-making: All women over age 40 should routinely be given the opportunity to receive information about breast cancer screening and informed decision-making. The decision regarding age of initiation and frequency of screening should be made after helping women understand potential benefits, harms and limitations of mammography. This decision should also take into account the patient's age, risk stratification (http://www.cancer.gov/bcrisktool), personal values, concerns and individual circumstances (Mandelblatt, 2009 [Low Quality Evidence]; Nelson, 2009 [Systematic Review]).
Various patient decision aids are available and can be useful tools; for example, this Web site provides an interactive screening mammography decision aid created by the University of Sydney:
http://www.mammogram.med.usyd.edu.au/.
Implementation Tools and Strategies:
Medications for the Risk Reduction of Primary Breast Cancer in Women