ACR Appropriateness Criteria ® Breast Cancer Screening

Abstract

Breast cancer screening recommendations are based on risk factors. For average-risk women, screening mammography and/or digital breast tomosynthesis is recommended beginning at age 40. Ultrasound (US) may be useful as an adjunct to mammography for incremental cancer detection in women with dense breasts, but the balance between increased cancer detection and the increased risk of a false-positive examination should be considered in the decision. For intermediate-risk women, US or MRI may be indicated as an adjunct to mammography depending upon specific risk factors. For women at high risk due to prior mantle radiation between the ages of 10 to 30, mammography is recommended starting 8 years after radiation therapy but not before age 25. For women with a genetic predisposition, annual screening mammography is recommended beginning 10 years earlier than the affected relative at the time of diagnosis but not before age 30. Annual screening MRI is recommended in high-risk women as an adjunct to mammography. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Mammographic Breast Density: Impact on Breast Cancer Risk and Implications for Screening

“…Multiple national and international societies, including the ACS, the NCCN, the American College of Radiology/Society of Breast Imaging (ACR/SBI), the American Society of Breast Surgeons, and the European Society of Breast Imaging, recommend annual screening with breast MR imaging as an adjunct to annual screening mammography in women who are high risk (63,44,76,77). As noted in the ACRIN 6666 data (71), there is no additional value of whole-breast US screening in women who can undergo mammography and breast MR imaging.…”

“…The ACR/SBI appropriateness criteria state that MR imaging of intermediate-risk women (ie, women with a personal history of breast cancer, lobular neoplasia, atypical ductal hyperplasia, or a 15%-20% lifetime risk for breast cancer) is "usually appropriate" and is rated as 7 out of 9 on the appropriateness scale (76). Screening wholebreast US is listed as 5 out of 9 and "may be appropriate."…”

Abbreviated Screening Protocol for Breast MRI

“…B reast magnetic resonance imaging (MRI) has been shown to have the highest sensitivity of all imaging modalities for the detection of breast cancer, a critically important factor in screening (1)(2)(3)(4)(5)(6)(7). The high sensitivity of breast MRI is largely because of improved contrast over mammography, particularly in women with dense breast tissue (1,8,9).…”

“…The high sensitivity of breast MRI is largely because of improved contrast over mammography, particularly in women with dense breast tissue (1,8,9). As a result, MRI has been increasingly used to help screen women at increased lifetime risk for breast cancer.…”

“…As a result, MRI has been increasingly used to help screen women at increased lifetime risk for breast cancer. The American College of Radiology Appropriateness Criteria gives contrast-enhanced MRI their highest rating for use in high-risk women ($20% lifetime risk; genetic mutation carriers, strong family history, and prior chest radiation) when used in conjunction with mammography (1). Similar recommendations for MRI screening in high-risk women exist from the American Cancer Society (9) and the National Comprehensive Cancer Care Network (10) as well as health systems in the United Kingdom (11) and Canada (12).…”