Committee on Practice Bulletins—Gynecology. This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology.
Health care providers should identify cases of breast, ovarian, colon, prostate, pancreatic, and other types of germline mutation-associated cancer in first-degree, second-degree, and possibly Permanent facial filler relatives as well as the age of diagnosis. Cancer treatment and survivorship facts and figures The purpose of this Practice Bulletin is to discuss breast cancer risk assessment, review breast cancer screening guidelines in average-risk women, and outline some of the controversies surrounding breast brexst screening. A number of validated breast cancer risk assess-ment tools are readily available online and can be completed quickly in an office setting. All rights reserved.
Oak apartments spokane valley wa. Breast Cancer Screening and Treatment: Resource Overview
These materials are for information purposes only and are not meant canccer be comprehensive. Overdiagnosis and Overtreatment Overdiagnosis occurs when screening detects cancer that would not have Women of the tracy to symptomatic cancer if left undetected Mental health disorders in adolescence are a significant problem, relatively common, and amenable to treatment or intervention. Strategies to reduce the risk of ovarian and fallopian tube cancers in women with known BRCA mutations include surveillance, chemoprevention, and surgery. Obstet Gynecol ;—1. Ann Intern Med ;—55; W— When should screening greast begin rlsk average-risk women? Some tools are better for certain risk factors and populations than others. Method of detection of breast cancer in low-income women. Earn up to 6 CME credits per issue. Copyright Radiation-induced breast cancer incidence and mortality from digital mammography screening: a modeling study. Women with a potentially increased risk of breast cancer based Acog and breast cancer risk screening initial history should have further risk assessment. Get immediate access, anytime, anywhere. Moderate alcohol intake and cancer incidence in women.
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- The American College of Obstetricians and Gynecologists has identified the following resources on breast cancer screening and shared decision making that may be helpful for ob-gyns, other health care providers, and patients.
- Among the changes, however, is an emphasis on patient—provider shared decision making to help women make informed, individualized decisions about when to start screening, the frequency of screening and when to end screening.
The American College of Obstetricians and Gynecologists has identified the following resources on breast cancer screening and shared decision making that may be helpful for ob-gyns, other health care providers, and patients. These materials are for information purposes only and are not meant to be comprehensive.
The resources may change without notice. At-risk patients should be referred to a specialist in cancer genetics. She discusses the current guidelines she follows, mammograms, timing of the initial screening, self breast exams, and breast exams by a health care professional. Early studies of the relationship between prior induced abortion and breast cancer risk were methodologically flawed.
This summary of the U. This webpage outlines the SHARE Approach , a five-step process developed by the Agency for Healthcare Research and Quality to support clinicians in engaging their patients in shared health-care decision making. The Breast Screening Decisions tool was developed by researchers at Weill Cornell Medical College and Memorial Sloan Kettering Cancer Center to help average-risk women aged 40—49 years make informed, personalized decisions about when to start and how often to have mammography for breast cancer screening.
This decision aid is intended for use in consultation with a physician. Women's Health Care Physicians. Read the Committee Opinion: Aromatase Inhibitors in Gynecologic Practice Practice Bulletin: Diagnosis and Management of Benign Breast Disorders members only " Diagnosis and Management of Benign Breast Disorders ," issued by ACOG in June , addresses the diagnosis and treatment of non-cancerous breast disorders including benign breast lesions and masses, nipple discharge, mastalgia or breast pain, inflammatory breast disorders, and skin changes of the breast.
Read the Practice Bulletin: Lynch Syndrome Committee Opinion: Tamoxifen and Uterine Cancer " Tamoxifen and Uterine Cancer ," issued by ACOG in June , addresses the risk of uterine cancer in breast cancer patients treated with Tamoxifen and recommends care to prevent and detect uterine cancer in women receiving the drug.
J Clin Oncol ;— This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. Self-detection remains a key method of breast cancer detection for U. The ACS and the U. However, the 5-year risk and the proportion of incident breast cancer cases were lower in 40—year-olds 5-year risk, 0.
Acog and breast cancer risk screening. ACOG Revises Breast Cancer Screening Guidance: Ob-Gyns Promote Shared Decision Making
ACOG Revises Breast Cancer Screening Guidance: Ob-Gyns Promote Shared Decision Making - ACOG
Committee on Practice Bulletins—Gynecology. This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care.
It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology.
Any updates to this document can be found on www. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.
Regular screening mammography starting at age 40 years reduces breast cancer mortality in average-risk women 2. Differences in balancing benefits and harms have led to differences among major guidelines about what age to start, what age to stop, and how frequently to recommend mammography screening in average-risk women 2 —4.
This can lead to missed opportunities to identify women at high risk of breast cancer and may result in applying average-risk screening recommendations to high-risk women. Risk assessment and identification of women at high risk allow for referral to health care providers with expertise in cancer genetics counseling and testing for breast cancer-related germline mutations eg, BRCA , patient counseling about risk-reduction options, and cascade testing to identify family members who also may be at increased risk.
The purpose of this Practice Bulletin is to discuss breast cancer risk assessment, review breast cancer screening guidelines in average-risk women, and outline some of the controversies surrounding breast cancer screening.
It will present recommendations for using a framework of shared decision making to assist women in balancing their personal values regarding benefits and harms of screening at various ages and intervals to make personal screening choices from within a range of reasonable options. Recommendations for women at elevated risk and discussion of new technologies, such as tomosynthesis, are beyond the scope of this document and are addressed in other publications of the American College of Obstetricians and Gynecologists ACOG 5—7.
It is estimated that , new cases of breast cancer, resulting in 40, deaths, will be diagnosed in women in the United States in 8.
An additional 63, new cases of ductal carcinoma in situ also will be diagnosed 8. Breast cancer mortality rates have decreased substantially during the past 50 years. This decrease has been attributed to early detection and improvements in breast cancer treatment 3. There are currently an estimated 3.
Certain reproductive factors influence breast cancer risk, particularly the risk of hormone receptor-positive breast cancer Box 1 6, 10— A systematic review indicates that nulliparity and longer intervals between menarche and age at first birth are associated with an increased risk of hormone receptor-positive breast cancer Other less consistently reported reproductive risk factors for breast cancer include older age at first birth, older age at menopause, and younger age at menarche.
In contrast, certain reproductive factors appear to decrease the risk of breast cancer. Family history of breast cancer, ovarian cancer including fallopian tube cancer and primary peritoneal cancer , and other types of germline mutation-associated cancer eg, prostate and pancreatic are associated with an increased risk of breast cancer. For family members with cancer, breast cancer onset at a young age is associated with an increased risk of the presence of a germline mutation. Atypical ductal hyperplasia, atypical lobular hyperplasia, and lobular carcinoma in situ are typically found incidentally upon histologic evaluation of abnormal mammography findings or breast masses Women with dense breasts diagnosed by mammography have a modestly increased risk of breast cancer.
Mammography has reduced sensitivity to detect breast cancer in women with dense breasts Breast cancer screening in women with dense breasts is beyond the scope of this document. Women treated for Hodgkin lymphoma with therapeutic chest radiation therapy between the ages of 10 years and 30 years and possibly as late as age 45 years are at an increased risk of breast cancer 20— Girls who are treated between the ages of 10 years and 14 years appear to be at greatest risk of future development of breast cancer.
Breast self-examination, breast self-awareness, clinical breast examination, and mammography all have been used alone or in combination to screen for breast cancer. Determining the appropriate combination of screening methods, the age to start screening, the age to stop screening, and how frequently to repeat the screening tests require finding the appropriate balance of benefits and harms. Determining this balance can be difficult because some issues, particularly the importance of harms, are subjective and valued differently from patient to patient.
This balance can depend on other factors, particularly the characteristics of the screening tests in different populations and at different ages. Varying judgments about the appropriate balance of benefits and harms have led to differences among the major guideline group recommendations for breast cancer screening Table 1 3, 4, The American College of Obstetricians and Gynecologists has reviewed these guidelines, their supporting evidence and rationale, and the recommendations for shared decision making embedded within them.
The next few sections of this Practice Bulletin present data on overall benefits and harms of mammography screening. To update its screening recommendations, the U. Preventive Services Task Force and the ACS recently conducted separate systematic reviews of the evidence for breast cancer screening in average-risk women 2, Studying the effect of mammography on mortality is methodologically challenging because of the large number of women needed and long follow-up periods involved.
Randomized and observational studies provide important information but have different limitations. Both systematic reviews combined randomized and observational studies and agreed that mammography generally decreases breast cancer mortality.
The ACS systematic review noted that the magnitude of the mortality reduction varied across study types and duration of follow-up 2. The ACS systematic review reported that screening mammography was associated with a decreased risk of breast cancer mortality in randomized controlled trials relative risk [RR], 0.
The U. Although the ACS and U. Preventive Services Task Force systematic reviews did not present evidence that screening mammography prevents the need for advanced cancer treatment, it is reasonable to assume that if screening reduces the risk of advanced breast cancer, it may reduce the need for advanced cancer treatment.
Strong recommendation. Data from National Comprehensive Cancer Network. Breast cancer screening and diagnosis. Version 1. Breast cancer screening for women at average risk: guideline update from the American Cancer Society [published erratum appears in JAMA ;].
Screening for breast cancer: U. Preventive Services Task Force recommendation statement. Ann Intern Med ;— The ACS systematic review also examined the effect of screening mammography on life expectancy. Although the review concluded that there was high-quality evidence that mammographic screening increases life expectancy by decreasing breast cancer mortality, the authors were not able to estimate the size of the increase Preventive Services Task Force conducted a systematic review specifically looking at harms associated with breast cancer screening in average-risk women The ACS systematic review 2 included a different analysis of the same data Preventive Services Task Force systematic review noted that many women reported pain during mammography; however, few considered it a deterrent to future screening Overdiagnosis occurs when screening detects cancer that would not have progressed to symptomatic cancer if left undetected Thus, overdiagnosis is the identification of cancer that remains indolent.
Overtreatment is defined as the initiation of treatment for an overdiagnosed cancer. It is difficult to determine the true rate of overdiagnosis because it is not ethically permissible to conduct natural history studies of untreated disease, so a variety of indirect methodologies have been used to estimate its frequency 28— There is significant uncertainty as to how often breast cancer overdiagnosis occurs.
Reported rates of overdiagnosis and overtreatment are, in part, related to the management of ductal carcinoma in situ. This lesion has a significantly lower risk than breast cancer, although many studies group it with breast cancer and its diagnosis typically leads to treatment. Modeling data also indicate that the risk of overdiagnosis appears to be lower with older age and with less frequent screening Preventive Services Task Force systematic review found no direct studies of radiation exposure from mammography but included a modeling study that estimated that the number of deaths caused by mammography radiation-induced cancer was 2 per , among women aged 50—59 years screened biennially, and 11 per , among women aged 40—49 years screened annually In this model, radiation from annual screening of , women aged 40—74 years was estimated to induce cases of breast cancer and 16 cases of breast cancer deaths, compared with cases of cancer deaths prevented by early detection through screening.
Shared decision making is a process in which patients and physicians share information, express treatment preferences, and agree on a treatment plan see Committee Opinion No. It combines the expertise of the physician, who provides the details of the clinical information, including the benefits eg, decreased risk of dying of breast cancer and harms eg, callbacks, benign breast biopsies, overdiagnosis , and the values of the patient, who shares her experiences, concerns, and priorities.
The clinical information can be provided in ways that are efficient for patients and physicians eg, online videos or reliable web pages, informational handouts, or face-to-face conversations. Shared decision making is particularly important for decisions regarding breast cancer screening because many choices involve personal preferences related to potential benefits and adverse consequences.
Breast cancer risk assessment is based on a combination of the various factors that can affect risk Box 1 6, 10— Health care providers should identify cases of breast, ovarian, colon, prostate, pancreatic, and other types of germline mutation-associated cancer in first-degree, second-degree, and possibly third-degree relatives as well as the age of diagnosis.
Women with a potentially increased risk of breast cancer based on initial history should have further risk assessment. Risk assessment is important to determine if a woman is at average or increased risk of breast cancer to guide counseling regarding breast cancer surveillance, risk reduction, and genetic testing.
Risk assessment should not be used to consider a woman ineligible for screening appropriate for her age. Information regarding screening and risk reduction for women at high risk is discussed elsewhere 4, 5, 35 , A number of validated breast cancer risk assess-ment tools are readily available online and can be completed quickly in an office setting.
Some tools are better for certain risk factors and populations than others. The Gail model www. A hereditary cancer risk assessment is conducted by a genetic counselor or other health care provider with expertise in cancer genetics and includes gathering family history information, risk assessment, education, and counseling This assessment may include genetic testing, if desired, after appropriate counseling and informed consent is obtained.
Average-risk women should be counseled about breast self-awareness and encouraged to notify their health care provider if they experience a change. Unlike breast self-examination, breast self-awareness does not include a recommendation for women to examine their breasts in a systematic way or on a routine basis. Rather, it means that a woman should be attuned to noticing a change or potential problem with her breasts.
Women should be educated about the signs and symptoms of breast cancer and advised to notify their health care provider if they notice a change such as pain, a mass, new onset of nipple discharge, or redness in their breasts. In its breast cancer screening guidelines, the U. Preventive Services Task Force did not change this recommendation in the update of its breast cancer screening guidelines 3. The ACS also no longer recommends breast self-examination for women at average risk of breast cancer because of the lack of evidence regarding improved outcomes Although there are no studies in the United States that have directly examined the effectiveness of breast self-awareness, based on the frequent incidence of self-detected breast cancer, patients should be counseled about breast self-awareness.
Screening clinical breast examination may be offered to asymptomatic, average-risk women in the context of an informed, shared decision-making approach that recognizes the uncertainty of additional benefits and the possibility of adverse consequences of clinical breast examination beyond screening mammography.
If performed for screening, intervals of every 1—3 years for women aged 25—39 years and annually for women 40 years and older are reasonable. Preventive Services Task Force on whether to perform screening clinical breast examination in women at average risk of breast cancer Table 1 3, 4, The recent ACS systematic review found no studies directly estimating the association between clinical breast examination and mortality 2.