Guideline for The Early Detection of Breast Cancer - Toward ...

2007 Update
Administered by the Alberta
Guideline for
Medical Association
The Early Detection of Breast Cancer
This guideline was written to provide guidance about the appropriate use of
screening tools for breast cancer and to help physicians and patients make
informed decisions about screening for breast cancer in asymptomatic women
of all ages. Due to the addition of important research related to breast
screening, this guideline will continue to be reviewed on an anuual basis.
RECOMMENDATIONS
Screening Procedures
Mammography, clinical breast examination and breast
self-examination can be used as screening procedures.
Breast ultrasound and MRI are not currently recommended
for routine screening.
Exclusions
The recommendations in this guideline do not apply to:
♦
♦
♦
Women with signs and symptoms suggesting breast
cancer;
Women with a personal history of breast cancer;
Men.
Mammography Screening in Women Under 40 Years
♦
Routine mammographic screening for women under
40 is not recommended.
Mammography Screening in Women aged 40 to 49
Mammography Screening in Women aged 50 to 69
♦
♦
Women aged 50 to 69 years should have a screening
mammogram at least every two years.
Annual mammography screening should be
considered in circumstances of increased risk.
Mammography Screening in Women Over 70 Years
♦
♦
The risk of breast cancer in this group is high.
Mammography screening every two years should
be continued taking into account individual health
factors and estimated life expectancy.
Mammography Screening in Women with a Genetic
Predisposition to Breast Cancer
♦
Some experts suggest that mammography screening
among this population should commence five to ten
years prior to the age of onset of breast cancer in
their family member. Consideration may be given
to referral to the Cancer Genetics Research Clinics.
(See Background & Appendix 1).
Clinical Breast Examination and Breast Self Exam
♦
CBE and BSE should be seen as complementary
examinations to mammography. (For CBE See
Appendix 2)
♦
Women aged 40 to 49 should have the opportunity to
access screening mammography. Physicians
should discuss with patients, the benefits and risks of
screening.
♦
Primary care physicians should discuss breast
self examination with all women by age 30.
Breast Implants
♦
There remains controversy regarding the degree
of benefit of screening mammography in this age
group. (See Background)
♦
Women with breast implants should be referred for
diagnostic mammography at age appropriate intervals.
♦
If a woman chooses to participate in mammography
screening, the recommended interval between
screens in this age group is one year.
The above recommendations are systematically developed statements to assist practitioner and patient
decisions about appropriate health care for specific clinical circumstances. They should be used as an
adjunct to sound clinical decision making.

BACKGROUND
Epidemiology
Breast cancer is one of the most serious health concerns of
Canadian women and is the most common form of cancer
in women excluding non-melanoma skin cancer. Breast
cancer accounts for 30% of all new cancer cases. 1,2,3,4 In
2001, 1,644 Alberta women were diagnosed with invasive
breast cancer and 425 women died of the disease. 5 Breast
cancer accounts for nearly 21% of all cancer deaths in
Alberta women. 1
Risk Factors
The lifetime risk for breast cancer is one in nine. The risk
however, varies over a woman’s lifetime. Table 1 reflects
the age specific risk of breast cancer for women. 6
Table One
Probability of Developing Breast Cancer
in the Next Five Years, by Age, for
Women Who Reside in Alberta and
Currently Do Not Have Breast Cancer
Age
Probability
35 1/384
40 1/208
45 1/128
50 1/109
55 1/94
60 1/78
65 1/70
70 1/65
Increasing age, being born in North America and
northwest Europe, and having two or more first degree
relatives with a history of breast cancer are identified as
the strongest risk factors.
There are many other identifiable risk factors, but few
are amenable to change. It is estimated that up to 80% of
women who develop breast cancer have no risk factors
other than being female, and in a higher risk age group. 7
Evidence from the WHI 8 studies indicate that in any
single year, 0.08 percent more women in the HRT group
developed breast cancer than women in the placebo
group, suggesting that the effect of HRT on the risk of
breast cancer is small.
Definition of Screening for Breast Cancer used in this
CPG
Breast cancer screening refers to the application of a
procedure to asymptomatic women for the purpose of
detecting unsuspected breast cancer at a stage when early
intervention can affect the outcome.
Mammography Screening
A normal screening mammography does not rule out breast
cancer in the presence of persistent palpable abnormalities.
Further evaluation may still be required.
Screening in Women Under 40 Years
Randomized controlled studies have not included women
in this age group. 9 Routine screening is not recommended.
Screening in Women Aged 40 to 49 Years
In women aged 40 to 49, breast cancer is the single
leading cause of death. 3,4 Some of the reservations about
making population-based recommendations for women in
this age group, are based on limitations in the scientific evidence
available to date. While there is emerging evidence
of benefit from some combined analyses of the randomized
trials, the benefit is smaller than in older women,
and is of borderline statistical significance. 10,11
There has been a lot of debate in the literature regarding
the reasons for the apparent decreased benefit of screening.
Evidence to date suggests that screening mammography
is less sensitive for women in their forties than
for older women. 12 It has also been suggested that due to
more rapid growth of tumours in this age group that the
interval between screens in some studies has been too
long to show a benefit. 13 Data suggests that annual mammography
in this age group will be required 14 in order to
detect breast cancer at its earliest stages and achieve a
reduction in breast cancer mortality similar to that seen in
older women. 14,15 Finally, there may be statistically insufficient
numbers of women in this age group included in
the controlled trials to definitively show a benefit. 16
Concerns have also been raised about the decreased
positive predictive value of any of the three breast screening
procedures in women in their forties when compared
to older women. In other words, the probability that a
younger woman would have a benign biopsy as a consequence
of screening is higher than for older women.

Women Aged 50 to 69 Years
Many studies have shown the efficacy of mammography
screening for breast cancer for women aged 50 to
69 years. Regular mammographic screening in this age
group is estimated to reduce mortality from breast carcinoma
by approximately one third. Because additional
benefit with annual screening has not been demonstrated,
screening every two years is often recommended. 9
Women Over 70 Years
The incidence of breast cancer increases with age, and
therefore women over 70 years continue to be at high
risk. Although no randomized clinical trials have
specifically addressed the efficacy of screening in this
age group, it should be continued in the context of individual
health factors and life expectancy.
Women a Genetic Predisposition for Breast Cancer
Women with a strong family history of breast cancer
should be advised of the availability of counselling and
information provided by the Cancer Genetics Research
Clinics. (See Appendix 1 for referral criteria)
The recommended screening interval for women in this
group is yearly beginning at age 40 or 5 - 10 years prior
to the age of onset of breast cancer in a first degree family
member. Additional screening tools for this group of
women are currently being studied including MRI, ultrasound,
and Sestamibi Nuclear Medicine Scans.
Radiation Risk
The risk of mammographically-induced cancer is generally
considered to be negligible. Some experts have expressed
concern over the theoretical risk of radiation-induced
breast cancers, especially among younger women. However,
the studies which have raised this concern involved
much higher levels of radiation than are found in present
day mammography. 17,18 The radiation dose delivered by
mammography is lower than that of an ordinary chest
X-ray.
Factors Affecting the Acceptance of Screening Recommendations
The strongest stimulus for a woman to participate in
mammography screening is the recommendation from
her physician. Studies indicate that many factors affect a
woman’s choice to participate in breast cancer screening.
Adverse factors include age, i.e., younger (40-49) and
older (70 plus) women; socioeconomically disadvantaged;
limited contact with a physician; single martial status;
unemployed and retired; country of birth and fewer years
since immigration, i.e., Asia, South and Central America,
Caribbean and Africa; lower educational attainment; and,
rural residence. 19,20,21 Physicians should ensure that all
women who would benefit from screening be informed of
its potential advantages.
SELECTED REFERENCES
1. National Cancer Institute, Canadian Cancer Statistics,
1997.
2. Statistics Canada. HEALTH REPORTS. Catalogue
82.003XPB.1997;9(1).
3. Gaudette LA, Silberger C, Altmayer CA et al. Trends
in breast cancer incidence and mortality. HEALTH
REPORTS. Statistics Canada, Catalogue 82.003-
XPB. 1996;8(2):29-37.
4. Bondy M, Luskbader E, Halabi S, et al. Validation
of a breast cancer risk assessment model in women
with a positive family history. Journal of the
National Cancer Institute 1994;86:620-25.
5. Alberta Cancer Board. Alberta cancer registry (2003).
Cancer statistics
6. Bryant HE, Brasher PMA. Risks and probabilities of
breast cancer: short term versus lifetime probabilities.
CMAJ 1994;150(2):211-216.
7. Alberta Cancer Board. A Snapshot of Cancer in
Alberta. 1996.
8. Women’s Health Initiative. NIH Publication No.
02-5200 October 2002.
9. Tabar L, Faberberg G, Day N, et al. What is the
optimum interval between mammographic screening
examinations? An analysis based on the latest results
of the Swedish two-county breast cancer screening
trial. International Journal of Cancer, 1987; 55: 547-
551.
10. Smart C, Hendrick R, Rutledge J, Smith R. Benefit
of mammography screening in women ages 40 to 49.
Current evidence from randomized controlled trials.
Cancer, April 1995; 75(7): 1619-1626.
11. American Cancer Society. Workshop on Guidelines
for Breast Cancer Detection. Chicago, March 1998.

12. Kerlikowske K, Grady D, Barclay J, et al. Effect
of age, breast density, and family history on the
sensitivity of first screening mammography. JAMA,
July 1996; 276(1): 33-38.
13. Feig S. Determination of mammographic screening
intervals with surrogate measures for women aged
40-49 years. Radiology, 1994; 193: 311-314.
14. Duffy S, Chen H, Tabar L, et al. Sojourn time,
sensitivity and positive predictive value of
mammography screening for breast cancer in
women aged 40-49. International Journal of
Epidemiology, 1996; 25(8): 1139-1145.
15 Tabar L, Fagerberg G, Chen H, et al. Tumour
development histology and grade of breast cancers:
prognosis and progression. International Journal of
Cancer, 1996; 66: 413-419.
16. Kopans D, Halpern E, Hulka C. Statistical power
in breast cancer screening trials and mortality
reduction among women 40-49 years with particular
emphasis on the national Breast Screening Study of
Canada. Cancer 1994; 74: 1196-1203.
17. Mettler F, Upton A, Kelsey C, et al. Benefits versus
risks from mammography: a critical reassessment.
Cancer, March 1996; 77(5): 903-909.
18. NIH Consensus Statement. Breast Cancer Screening
of Women Ages 40-49. January 1997; 15(1).
19. Dodd GD. Screening for Breast Cancer. CANCER
SUPPLEMENT. August 1, 1993; 72(3):1038-1042
20. Maxwell CJ, Parboosingh J, Kozak JF,
Desjardins-Denault SD. Factors Important in
Promoting Mammography Screening among
Canadian Women. Canadian Journal of Public
Health,Sept 1997; 88(5):346-350.
21. Gentleman JF, Lee J. Who Doesn’t get a
Mammogram? Statistics Canada, Catalogue
82-003-XPB, Health Reports, Summer 1997. Vol.9,
No.1
22. Bates B. A Guide to Physical Examination and History
Taking. (pp317-328) 4th Edition, 1987 J.B. Lippincott
Company, Philadelphia.
Toward Optimized Practice (TOP)
Program
Arising out of the 2003 Master Agreement, TOP succeeds
the former Alberta Clinical Practice Guidelines program, and
maintains and distributes Alberta CPGs. TOP is a health quality
improvement initiative that fits within the broader health system
focus on quality and complements other strategies such as Primary
Care Initiative and the Physician Office System Program.
The TOP program supports physician practices, and the teams
they work with, by fostering the use of evidence-based best
practices and quality initiatives in medical care in Alberta. The
program offers a variety of tools and out-reach services to help
physicians and their colleagues meet the challenge of keeping
practices current in an environment of continually emerging
evidence.
TO PROVIDE FEEDBACK
The Early Detection of Breast Cancer Working Group is a multidisciplinary
team composed of a family physician, general practitioners,
radiologists, general surgeons, a gynecologist, oncologist,
pathologist, epidemiologist, Medical Officer of Health, nurse,
medical student, public representatives, the Canadian Cancer
Society, and Breast Cancer Policy Council representatives.
The Working Group encourages your feedback. If you need further
information or if you have difficulty applying this guideline,
please contact:
Clinical Practice Guidelines Manager
TOP Program
12230 - 106 Avenue NW
Edmonton AB T5N 3Z1
Phone: 780.482.0319
or toll free 1.866.505.3302
Fax: 780.482.5445
Email: cpg@topalbertadoctors.org
Website: www.topalbertadoctors.org
Early Detection of Breast Cancer - April 1999
Reviewed - August 2000
Reviewed - March 2002
Reviewed - November 2004

APPENDIX 1: CANCER GENETICS CLINICS
CANCER GENETICS CLINIC
Contact Information
Cross Cancer Institute and Edmonton/Calgary Genetics Clinics.
By Mail:
Edmonton Genetics Clinic
Clinical Sciences Building B-139
University of Alberta
Edmonton, Alberta T6G 2B7
By Telephone:
Cross Cancer Institute (780) 432-8422
Edmonton Genetics Clinic (780) 407-7333
Cancer Genetics Research Clinic (403) 670-2438
Cancer Genetics Research Clinic
Tom Baker Cancer Centre
1331-29th Street NW
Calgary, Alberta T2N 4N2
Note: Referrals MUST be made by a physician and are preferred by mail. Appointments will be made with
patient(s) after initial work up completed.
Referral Criteria
The following are offered as considerations for selecting women who may benefit from genetic counselling. The
criteria do not necessarily define women at increased risk of developing breast carcinoma who merit earlier or
more frequent mammographic screening.
• Personal or close family history of breast cancer < 35 years; ovarian cancer < 50 years; bilateral breast cancer
- first onset < 50 years; or breast and ovarian cancer
• Two related family members with breast cancer and/or ovarian cancer with onset in both < 50 years
• Three or more related family members with breast and/or ovarian cancer, one onset < 50 years
• Four or more related family members with breast and/or ovarian cancer, any age
• Ashkenazi descent, breast and/or ovarian cancer, any age
• Any case of male breast cancer
• Known mutation in a cancer susceptibility gene such as the BRCA1 or BRCA2 gene is present in a family
member
• Families which may not meet the above criteria, but have a strong family history suggestive of the presence of
a mutated cancer susceptibility gene

APPENDIX 2: CLINICAL BREAST EXAMINATION
Clinical breast examination (CBE) may detect some breast cancers which are not evident on mammography. However, the
effectiveness of CBE depends upon systematic examination of all quadrants of both breasts and all regional lymph nodes. One
systematic approach is illustrated below. 22
Region
Examined
BREASTS
AXILLAE
AXILLARY LYMPH
NODES
INFRACLAVICULAR
LYMPH NODES
Examination
Skills and Focus
Inspection
BREAST, AREOLA, NIPPLE
Inspection
AXILLAE
Palpation
CENTRAL,
PECTORAL,
SUBSCAPULAR,
LATERAL LYMPH NODES
Palpation
INFRACLAVICULAR
Procedures and Techniques
Client in SITTING position disrobed to waist. Inspect breast, areola and
nipple bilaterally from anterior and lateral view:
1. With arms at side
2. With arms raised over head
3. With hands pressed against hips
or
With hands squeezed together at shoulder level
4. DO ONLY IF breasts are pendulous or very large: inspect with
client leaning forward.
Inspects skin of axillae with arms raised over head
Supports client’s “L” hand and wrist with “L” hand to examine “L”
axilla and reverses for “R” axilla. Cup fingers together. Reaches as
high as possible into axilla
1. Brings fingers down over ribs and feels for CENTRAL nodes
2. Feels inside anterior axillary folds (PECTORAL)
3. Feels inside posterior axillary folds (SUBSCAPULAR)
4. Feels against humerus (LATERAL)
Palpates bilaterally for INFRACLAVICULAR nodes in 1st interspace
with finger pads
SUPRACLAVICULAR
LYMPH NODES
BREASTS
Palpation
SUPRACLAVICULAR
Inspection
BREAST, AREOLA,
NIPPLE (same as above)
Palpation
BREAST, AREOLA,
NIPPLE and
TAIL OF SPENCE
Palpates bilaterally for SUPRACLAVICULAR nodes above clavicle
with finger pads
Client SUPINE, with pillow removed from under head. Uses small
pillow under client’s shoulder on side examined to shift breasts medially
(NO PILLOW IF BREASTS ARE SMALL)
1. Inspects breasts.
Palpates each breast:
1. Asks client to move arm away from chest on side being examined
2. Uses flat of 4 fingers, in a rotary motion to compress breast tissue
3. Flexes, from the wrist, not the fingers
4. Applies moderate pressure, keeping constant contact with skin
5. Moves back and forth across breast in straight lines, making
constant small circles
6. Slides hand down 1 finger width for each pass
7. Covers full area from below clavicle to 3 cm below breast from
anterior axillary line to midsternal line:
a) glandular tissue c) nipple
b) areolar area d) Tail of Spence
Adopted and reproduced with permission from: Skillen DL & Day R. (Eds). 1998. A syllabus for adult health assessment (pp.61-62). Edmonton: University of
Alberta, Faculty of Nursing.