Breast Cancer Screening (Clinical)

Overview

Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer

Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer is a disease characterized by malignant transformation Transformation Change brought about to an organism’s genetic composition by unidirectional transfer (transfection; transduction, genetic; conjugation, genetic, etc.) and incorporation of foreign DNA into prokaryotic or eukaryotic cells by recombination of part or all of that DNA into the cell’s genome. Bacteriology of the epithelial cells of the breast.

Epidemiology^[4,5,8]

• Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer is the most common cancer in women worldwide.
• Accounts for 29% of all malignant diseases among women in the United States
• Incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency: 125 cases per 100,000 women
• Risk increases with age, with 90% of cases occurring in women > 40 years of age
• Male breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer accounts for < 1% of total cases.
• An important cause of death in women:
  • United States: the 2nd-leading cause of cancer-related deaths
  • Developing countries: the leading cause of cancer-related deaths
• Early detection and improved treatments have reduced death rates.

Overview of screening Screening Preoperative Care process^[4,12]

• Goal of screening Screening Preoperative Care: detect preclinical disease in healthy, asymptomatic patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
• Best for:
  • Situations in which early detection and treatment reduce mortality Mortality All deaths reported in a given population. Measures of Health Status as compared with later diagnosis and treatment
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship most likely to develop the disease
• Process:
  • Assess a patient’s risk for breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer, 
  • Baseline risk determines the best methods and frequencies for screening Screening Preoperative Care.
  • Perform screening Screening Preoperative Care tests.
  • Follow-up abnormal screening Screening Preoperative Care test results with further testing based on initial results

Risk factors for breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer^[4]

• Family history Family History Adult Health Maintenance:
  • Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer in 1st- or 2nd-degree relatives (mother, grandmother, sister)
  • Ashkenazi Jewish descent
• Hormonal influences:
  • Long hormone exposure due to:
    • Early menarche Menarche The first menstrual cycle marked by the initiation of menstruation. Menstrual Cycle 
    • Late menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause
    • Higher age at 1st delivery (> 30 years of age)
    • Nulliparity
    • Hormone replacement therapy Hormone Replacement Therapy Hormone replacement therapy (HRT) is used to treat symptoms associated with female menopause and in combination to suppress ovulation. Risks and side effects include uterine bleeding, predisposition to cancer, breast tenderness, hyperpigmentation, migraine headaches, hypertension, bloating, and mood changes. Noncontraceptive Estrogen and Progestins after menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause (> 5 years)
  • Note: Breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding for at least 6 months decreases the risk of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer.
• Genetic mutations Genetic Mutations Carcinogenesis (examples):
  • BRCA1 (on chromosome Chromosome In a prokaryotic cell or in the nucleus of a eukaryotic cell, a structure consisting of or containing DNA which carries the genetic information essential to the cell. Basic Terms of Genetics 17q)
  • BRCA2 (on chromosome Chromosome In a prokaryotic cell or in the nucleus of a eukaryotic cell, a structure consisting of or containing DNA which carries the genetic information essential to the cell. Basic Terms of Genetics 13q)
  • p53 (on chromosome Chromosome In a prokaryotic cell or in the nucleus of a eukaryotic cell, a structure consisting of or containing DNA which carries the genetic information essential to the cell. Basic Terms of Genetics 17)
• Increasing age
• Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer on the contralateral side
• Prior breast biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma with:
  • Atypical hyperplasia Atypical Hyperplasia Benign Breast Conditions (lobular or ductal)
  • Lobular carcinoma in situ
• Dense breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy
• History of chest radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma as a young woman (10‒30 years old)
• Lifestyle factors that increase the risk:
  • High-fat diet
  • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity (especially after menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause)
  • Heavy alcohol use
  • Tobacco

Mnemonic:

BReast- CA CA Condylomata acuminata are a clinical manifestation of genital HPV infection. Condylomata acuminata are described as raised, pearly, flesh-colored, papular, cauliflower-like lesions seen in the anogenital region that may cause itching, pain, or bleeding. Condylomata Acuminata (Genital Warts)ncer 1 and 2: BRCA1 and BRCA2 are the mutated genes Genes A category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms. DNA Types and Structure in breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer.

Initial risk assessment Risk assessment The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. Preoperative Care^[4,12]

Details of the patient’s medical and personal history are needed to determine their risk:

• Personal and family history Family History Adult Health Maintenance of breast, ovarian, tubal, or peritoneal cancer
• Ancestry (associated with BRCA1 and BRCA2)
• Known carrier Carrier Vaccination of a gene mutation Gene Mutation Myotonic Dystrophies for breast or ovarian cancer Ovarian cancer Ovarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer:
  • If not known, determine the need for genetic testing Genetic Testing Detection of a mutation; genotype; karyotype; or specific alleles associated with genetic traits, heritable diseases, or predisposition to a disease, or that may lead to the disease in descendants. It includes prenatal genetic testing. Myotonic Dystrophies based on risk factors.
  • Genetic testing Genetic Testing Detection of a mutation; genotype; karyotype; or specific alleles associated with genetic traits, heritable diseases, or predisposition to a disease, or that may lead to the disease in descendants. It includes prenatal genetic testing. Myotonic Dystrophies for hereditary breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer is recommended when specific criteria are met MET Preoperative Care (criteria vary slightly according to organization (see below)).
• Mammographic breast density
• High-risk lesion on a previous breast biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma
• History of chest radiotherapy (age 10–30 years)

A patient’s risk for developing breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer can be classified as:

• Average:
  • Have none of the above risk factors (most patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship)
  • Lifetime risk < 15%
• Moderate:
  • Most women with a family history Family History Adult Health Maintenance of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer in a 1st-degree relative, but no known genetic syndrome
  • Lifetime risk 15%‒20%
• High:
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with:
    • A known genetic predisposition
    • Personal history of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
    • History of chest irradiation between the ages of 10 and 30 years
  • Lifetime risk > 20%

Determining the need for genetic evaluation:

Criteria from the National Comprehensive Cancer Network (NCCN),^[10] the American College of Obstetricians and Gynecologists (ACOG), and the Society of Gynecologic Oncologists (SGO)^[9] for genetic evaluation of hereditary breast and ovarian cancer Ovarian cancer Ovarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer include:

• Individuals who are diagnosed with breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer OR who have a 1st-degree (or several close) relatives diagnosed with any of the following:
  • Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer at ≤ 45 years of age
  • Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer at ≤ 50 years of age with unknown family history Family History Adult Health Maintenance
  • Triple-negative (ER‒, PR‒, HER2 HER2 A cell surface protein-tyrosine kinase receptor that is overexpressed in a variety of adenocarcinomas. It has extensive homology to and heterodimerizes with the EGF receptor, the ERBB-3 receptor, and the ERBB-4 receptor. Activation of the erbB-2 receptor occurs through heterodimer formation with a ligand-bound erbB receptor family member. Targeted and Other Nontraditional Antineoplastic Therapy‒) breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer at ≤ 60 years of age
  • Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer at any age with Ashkenazi Jewish ancestry
  • ≥ 2 primary breast cancers in the same individual
  • Epithelial ovarian, tubal, or peritoneal cancer (ever)
  • Pancreatic cancer
  • Metastatic prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer
• Individual unaffected by cancer but with 1 of the following factors that increase likelihood of an inherited risk of breast, tubal, ovarian, or peritoneal cancer:
  • Close relatives with criteria listed above
  • Close relative carrying a known BRCA1 or BRCA2 mutation Mutation Genetic mutations are errors in DNA that can cause protein misfolding and dysfunction. There are various types of mutations, including chromosomal, point, frameshift, and expansion mutations. Types of Mutations
  • Close relative with male breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
• Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer at any age PLUS 1 of the following:
  • ≥ 1 close relative with:
    • Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer at ≤ 50 years of age
    • Epithelial ovarian, tubal, or peritoneal cancer (ever)
    • Pancreatic cancer
    • Male breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer or high-grade (Gleason score ≥ 7) /metastatic prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer
  • ≥ 2 close relatives with breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer at any age
• Note: Close relatives are defined as 1st degree (parent, sibling, children), 2nd degree (grandparent, grandchild, aunt/uncle, niece/nephew, half-sibling), or 3rd degree (1st cousin, great-grandparent, great-grandchild).

Familial risk assessment Risk assessment The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. Preoperative Care tools:

• Help determine need for in-depth genetic counseling Genetic Counseling An educational process that provides information and advice to individuals or families about a genetic condition that may affect them. The purpose is to help individuals make informed decisions about marriage, reproduction, and other health management issues based on information about the genetic disease, the available diagnostic tests, and management programs. Psychosocial support is usually offered. Myotonic Dystrophies for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with personal history or family history Family History Adult Health Maintenance of breast, ovarian, tubal, or peritoneal cancer 
• Tools include:^[2]
  • Ontario Family History Family History Adult Health Maintenance Risk Assessment Risk assessment The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. Preoperative Care Tool
  • Manchester Scoring System
  • Referral screening Screening Preoperative Care tool
  • Pedigree Pedigree The record of descent or ancestry, particularly of a particular condition or trait, indicating individual family members, their relationships, and their status with respect to the trait or condition. Basic Terms of Genetics assessment tool
  • 7-Question Family History Family History Adult Health Maintenance Screening Screening Preoperative Care Tool
  • International Breast Cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer Intervention Study (IBIS) model (also known as Tyrer-Cuzick model)^[3]
    • Recommended by the American Society of Breast Surgeons (ASBrS)
    • Takes into account family and personal history of cancer, breast density, and biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma results
    • IBIS web tool
  • BRCAPRO (calculates the probability Probability Probability is a mathematical tool used to study randomness and provide predictions about the likelihood of something happening. There are several basic rules of probability that can be used to help determine the probability of multiple events happening together, separately, or sequentially. Basics of Probability of carrying BRCA1 and/or BRCA2 mutation Mutation Genetic mutations are errors in DNA that can cause protein misfolding and dysfunction. There are various types of mutations, including chromosomal, point, frameshift, and expansion mutations. Types of Mutations)
• Positive results should lead to genetic counseling Genetic Counseling An educational process that provides information and advice to individuals or families about a genetic condition that may affect them. The purpose is to help individuals make informed decisions about marriage, reproduction, and other health management issues based on information about the genetic disease, the available diagnostic tests, and management programs. Psychosocial support is usually offered. Myotonic Dystrophies and potentially genetic testing Genetic Testing Detection of a mutation; genotype; karyotype; or specific alleles associated with genetic traits, heritable diseases, or predisposition to a disease, or that may lead to the disease in descendants. It includes prenatal genetic testing. Myotonic Dystrophies.
• Genetic counseling Genetic Counseling An educational process that provides information and advice to individuals or families about a genetic condition that may affect them. The purpose is to help individuals make informed decisions about marriage, reproduction, and other health management issues based on information about the genetic disease, the available diagnostic tests, and management programs. Psychosocial support is usually offered. Myotonic Dystrophies and testing are not recommended for women with no personal or family history Family History Adult Health Maintenance or ancestry associated with BRCA1 or BRCA2.

Risk prediction models^[3,4]

Prediction models calculating the risk of developing breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer (and in some, gynecologic cancer):

• Breast Cancer Risk Assessment Tool Breast Cancer Risk Assessment Tool Breast Cancer Screening ( Gail model GAIL model Breast Cancer Screening): 
  • The most commonly used risk model
  • Indicated for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with no personal or strong family history Family History Adult Health Maintenance of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer (including ductal or lobular carcinoma in situ)
  • Takes into account age, ethnicity, age at menarche Menarche The first menstrual cycle marked by the initiation of menstruation. Menstrual Cycle, parity Parity The number of offspring a female has borne. It is contrasted with gravidity, which refers to the number of pregnancies, regardless of outcome. Pregnancy: Diagnosis, Physiology, and Care, and family history Family History Adult Health Maintenance of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
  • Less precise for older women
  • Cannot be used in certain subgroups (such as patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with genetic mutations Genetic Mutations Carcinogenesis, e.g., BRCA1 or BRCA2 mutations)
  • Gail model calculator
• Other validated assessment tools:^[4]
  • CanRisk Web Tool (previously known as BOADICEA (Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm)):
    • From the given family history Family History Adult Health Maintenance, the tool calculates the risks of breast or ovarian cancer Ovarian cancer Ovarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer in women. 
    • Also used to calculate the probability Probability Probability is a mathematical tool used to study randomness and provide predictions about the likelihood of something happening. There are several basic rules of probability that can be used to help determine the probability of multiple events happening together, separately, or sequentially. Basics of Probability of being BRCA1 or BRCA2 carriers Carriers The Cell: Cell Membrane
    • CanRisk Web Tool 
  • Claus model: uses age at diagnosis of 1st- and 2nd-degree relatives (with a history of breast and ovarian cancer Ovarian cancer Ovarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer) to estimate the lifetime risk for breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer 

Strategies for Screening

Breast examination Breast examination Physical examination of the breasts is important both in the evaluation of a breast complaint and screening for asymptomatic breast pathology such as a breast mass. The examination involves inspection of the breasts to look for asymmetry or skin/nipple changes, as well as palpation of the breasts, nipples, and axilla. Coupled with medical history, the outcome of a breast examination can be normal, lead to a clinical diagnosis (e.g., infection), or require additional diagnostic evaluation. Examination of the Breast

• Self-examination:^[4]
  • The regular Regular Insulin, repetitive inspection Inspection Dermatologic Examination of one’s own breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy for the purpose of detecting breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
  • Generally discouraged
  • Can lead to unnecessary procedures (e.g., mammograms and biopsies)
  • ACOG encourages teaching women “breast awareness” over self-exams^[4]
    • Breast awareness: A woman’s awareness of the normal appearance and feel of her breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy
    • Women should be educated about signs and symptoms of potential cancer, including a new mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast, nipple Nipple The conic organs which usually give outlet to milk from the mammary glands. Examination of the Breast discharge, redness Redness Inflammation, or pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.
    • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship should notify their healthcare provider if they notice a change.
• Clinical examination:^[1,3–6]
  • A clinical breast exam performed by a healthcare provider
  • Generally not recommended as a screening Screening Preoperative Care exam for asymptomatic average-risk women (some societies note it may be used as an adjunct only)
  • Utilized in the case of:
    • Women with a high risk (initial age differs depending on risk factors)
    • Any breast complaints or abnormalities
    • Low-resource settings
• Localizing breast lesions:
  • If there is a vague or large area, then the affected breast quadrant may be noted.
  • If there is a focal lesion, then the lesion will be localized by the clock face position and distance from the nipple Nipple The conic organs which usually give outlet to milk from the mammary glands. Examination of the Breast.

Mammography Mammography Radiographic examination of the breast. Breast Cancer Screening^[3,7,13]

Mammography Mammography Radiographic examination of the breast. Breast Cancer Screening is the most effective method of detecting early breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer, consistently demonstrating a 20%–40% decrease in mortality Mortality All deaths reported in a given population. Measures of Health Status among screened women:

• High false-negative rate:
  • May miss an average of 20% of breast cancers
  • If there is clinical suspicion for malignancy Malignancy Hemothorax, a negative mammogram Mammogram Fibrocystic Change does not rule out cancer, and further investigation is warranted.
• Types:
  • Screen film mammography Screen Film Mammography Breast Cancer Screening: mostly replaced by digital mammography Digital Mammography Breast Cancer Screening in well-resourced countries
  • Digital mammography Digital Mammography Breast Cancer Screening (2-D mammography Mammography Radiographic examination of the breast. Breast Cancer Screening): preferred for dense breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy (approximately 50% of all women)
  • Digital breast tomosynthesis Digital breast tomosynthesis Premature separation of the normally implanted placenta from the uterus. Signs of varying degree of severity include uterine bleeding, uterine muscle hypertonia, and fetal distress or fetal death. Breast Cancer Screening (DBT; 3-D mammography 3-D mammography Premature separation of the normally implanted placenta from the uterus. Signs of varying degree of severity include uterine bleeding, uterine muscle hypertonia, and fetal distress or fetal death. Breast Cancer Screening):
    • Takes images from many angles to obtain a 3-dimensional picture
    • Improves the sensitivity and specificity Sensitivity and Specificity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Specificity is the probability of correctly determining the absence of a condition. Epidemiological Values of Diagnostic Tests of mammography Mammography Radiographic examination of the breast. Breast Cancer Screening
    • Preferred by the American College of Breast Surgeons^[3]
  • Computer-aided detection Computer-Aided Detection Breast Cancer Screening (CAD) often used:^[13]
    • An artificial intelligence (AI) technique that uses pattern recognition to highlight suspicious features and marks the features for the radiologist to review
    • CAD decreases oversights. 
    • The European Commission recommends using AI as part of screening Screening Preoperative Care programs.^[7]
• Screening Screening Preoperative Care versus diagnostic mammography Mammography Radiographic examination of the breast. Breast Cancer Screening:^[13]
  • Screening Screening Preoperative Care mammography Mammography Radiographic examination of the breast. Breast Cancer Screening:
    • Performed on a woman with no symptoms or signs of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
    • Two standard views (+/– additional views) of each breast are obtained.
  • Diagnostic mammography Mammography Radiographic examination of the breast. Breast Cancer Screening:
    • A study providing more detailed images; views are tailored to the abnormality being evaluated. 
    • Performed on a woman who has a breast lesion suspicious for cancer either on clinical grounds or by findings on a screening Screening Preoperative Care mammogram Mammogram Fibrocystic Change
• Single versus double reading:^[7,13]
  • Single reading: Images are reviewed by a single radiologist (typical in the US).
  • Double reading: Images are reviewed by 2 radiologists, either independently or together as a consensus (standard in much of Europe).
  • The European Commission prefers double reading plus AI.^[7]
• Abnormal findings suggestive of malignancy Malignancy Hemothorax:^[13]
  • Masses (especially when they appear spiculated)
  • Calcifications, especially:
    • Grouped microcalcifications
    • Linear or linear branching microcalcifications
    • Pleomorphic Pleomorphic Bacteroides calcifications
  • Asymmetries
  • Architectural distortion Distortion Defense Mechanisms
• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with breast implants:
  • Radiopaque Radiopaque An object of high density that blocks X-rays (looks white) X-rays content makes mammography Mammography Radiographic examination of the breast. Breast Cancer Screening difficult.
  • Involves 4 views (instead of the usual 2) per breast

Magnetic resonance imaging (MRI)^[11]

• Indicated as supplementary screening Screening Preoperative Care along with mammography Mammography Radiographic examination of the breast. Breast Cancer Screening in women with a high risk of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer:
  • BRCA1 or BRCA2 mutations
  • Strong family histories of breast and/or ovarian cancer Ovarian cancer Ovarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer
  • History of chest irradiation between the ages of 10 and 30
• May be appropriate in women at intermediate risk of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer:^[11]
  • Personal history of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
  • Lobular neoplasia
  • Atypical ductal hyperplasia Atypical Ductal Hyperplasia Benign Breast Conditions
• Used to follow up an abnormal or inconclusive mammogram Mammogram Fibrocystic Change result
• Higher false positive False positive An FP test result indicates that a person has the disease when they do not. Epidemiological Values of Diagnostic Tests rates in women with dense breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy, leading to unneeded biopsies
• Despite the increased sensitivity for malignancy Malignancy Hemothorax, there is no evidence of a decreased mortality Mortality All deaths reported in a given population. Measures of Health Status benefit.

Ultrasound (US)^[11,13]

• Not routinely used for screening Screening Preoperative Care due to a high false-positive rate
• Primarily used for:
  • Diagnostic follow-up of an abnormal mammogram Mammogram Fibrocystic Change
  • 1st-choice imaging method for evaluating a breast mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast in women < 30 years of age
• Can be considered as an adjunct in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with dense breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy

BI-RADS categories^[13,14]

The Breast Imaging Reporting and Data System The Breast Imaging Reporting And Data System Breast Cancer Screening (BI-RADS):

• A categorization Categorization Types of Variables system to help determine the risk of malignancy Malignancy Hemothorax based on the findings of imaging studies (e.g., mammography Mammography Radiographic examination of the breast. Breast Cancer Screening, ultrasonography, or MRI)
• Provides a category from 0 to 6 that is associated with specific management recommendations
• Standardizes imaging reports
• Components of the BI-RADs report include:
  • Indication for the study
  • Prior images reviewed
  • Assessment of breast density:
    • 1: Breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy are almost entirely fatty
    • 2: Scattered areas of fibroglandular density
    • 3: Heterogeneously dense breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy, which may obscure small masses
    • 4: Extremely dense breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy, which lowers the sensitivity of mammography Mammography Radiographic examination of the breast. Breast Cancer Screening
  • Description of abnormalities
  • Summary, including the final BI-RADs assessment category (0‒6)

Screening for Average- and Moderate-Risk Individuals

Average risk

Society– and government-sponsored guidelines differ in:

• The recommended age to start regular Regular Insulin mammography Mammography Radiographic examination of the breast. Breast Cancer Screening
• Frequency of mammography Mammography Radiographic examination of the breast. Breast Cancer Screening (annually or biennially)
• Discontinuation of screening Screening Preoperative Care

Understanding guideline differences

• The primary reason for the variance in recommendation is that the societies and organizations weigh benefits and harms slightly differently from one another. 
• This, however, can be very confusing for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship (and providers), so counseling women in order to allow for shared decision-making is typically encouraged.

Moderate risk^[12]

• A similar approach to average-risk patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
• Supplemental screening Screening Preoperative Care with MRI or US can be offered on a case-by-case basis.

Screening for High-Risk Individuals

High-risk individuals are defined by the ASBrS and the NCCN as people with:^[3]

• A BRCA gene mutation Gene Mutation Myotonic Dystrophies (or other hereditary mutations known to increase the risk of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer)
• A very strong family history Family History Adult Health Maintenance of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer and who have not undergone genetic testing Genetic Testing Detection of a mutation; genotype; karyotype; or specific alleles associated with genetic traits, heritable diseases, or predisposition to a disease, or that may lead to the disease in descendants. It includes prenatal genetic testing. Myotonic Dystrophies
• A history of chest irradiation between ages 10 and 30
• > 20% estimated lifetime risk of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer based on risk assessment Risk assessment The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. Preoperative Care tools (e.g., IBIS/Tyrer-Cuzick, BRCAPro, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC).)

Screening Screening Preoperative Care recommendations^[9]

• Ages 25–29:
  • Clinical breast exam every 6–12 months
  • Annual radiographic screening Screening Preoperative Care, MRI preferred 
• Ages ≥ 30:
  • Annual mammography Mammography Radiographic examination of the breast. Breast Cancer Screening (DBT often preferred) plus annual MRI 
  • Exams are typically alternated every 6 months (e.g., mammography Mammography Radiographic examination of the breast. Breast Cancer Screening annually in January with MRI annually in July).

Risk reduction^[15,20]

Nonsurgical:

• Target modifiable risk factors:
  • Regular Regular Insulin physical exercise
  • Weight loss Weight loss Decrease in existing body weight. Bariatric Surgery
  • Decrease alcohol consumption
  • Smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases cessation
  • There is no evidence that dietary changes reduce risk.
• Chemoprevention:^[15,20]
  • USPSTF:^[15] Risk-reducing medications are recommended for high-risk women ≥ 35 years of age (for a total of 5 years).
  • Considered in women at a high risk of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
  • Selective estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy receptor Receptor Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors modulators ( SERMs SERMs A structurally diverse group of compounds distinguished from estrogens by their ability to bind and activate estrogen receptors but act as either an agonist or antagonist depending on the tissue type and hormonal milieu. They are classified as either first generation because they demonstrate estrogen agonist properties in the endometrium or second generation based on their patterns of tissue specificity. Antiestrogens):
    • Tamoxifen Tamoxifen One of the selective estrogen receptor modulators with tissue-specific activities. Tamoxifen acts as an anti-estrogen (inhibiting agent) in the mammary tissue, but as an estrogen (stimulating agent) in cholesterol metabolism, bone density, and cell proliferation in the endometrium. Antiestrogens 20 mg by mouth once daily for 5 years
    • Raloxifene Raloxifene A second generation selective estrogen receptor modulator (SERM) used to prevent osteoporosis in postmenopausal women. It has estrogen agonist effects on bone and cholesterol metabolism but behaves as a complete estrogen antagonist on mammary gland and uterine tissue. Other Antiresorptive Drugs 60 mg by mouth once daily for 5 years (or longer in women with osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis)
    • Indicated for BRCA2 carriers Carriers The Cell: Cell Membrane who opt out of prophylactic mastectomy Mastectomy Surgical procedure to remove one or both breasts. Fat Necrosis of the Breast 
    • Less effective than risk-reducing surgery
    • Used in pre- or postmenopausal women
    • Choosing a SERM: Raloxifene Raloxifene A second generation selective estrogen receptor modulator (SERM) used to prevent osteoporosis in postmenopausal women. It has estrogen agonist effects on bone and cholesterol metabolism but behaves as a complete estrogen antagonist on mammary gland and uterine tissue. Other Antiresorptive Drugs results in a smaller reduction of new breast cancers as compared with tamoxifen Tamoxifen One of the selective estrogen receptor modulators with tissue-specific activities. Tamoxifen acts as an anti-estrogen (inhibiting agent) in the mammary tissue, but as an estrogen (stimulating agent) in cholesterol metabolism, bone density, and cell proliferation in the endometrium. Antiestrogens, but it has a lower risk of endometrial cancer Endometrial Cancer Endometrial carcinoma (EC) is the most common gynecologic malignancy in the developed world, and it has several histologic types. Endometrioid carcinoma (known as type 1 EC) typically develops from atypical endometrial hyperplasia, is hormonally responsive, and carries a favorable prognosis. Endometrial Hyperplasia and Endometrial Cancer and thrombosis Thrombosis Formation and development of a thrombus or blood clot in the blood vessel. Epidemic Typhus and is also a treatment for osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis.^[20]
  • Aromatase Aromatase An enzyme that catalyzes the desaturation (aromatization) of the ring a of C19 androgens and converts them to C18 estrogens. In this process, the 19-methyl is removed. This enzyme is membrane-bound, located in the endoplasmic reticulum of estrogen-producing cells of ovaries, placenta, testes, adipose, and brain tissues. Aromatase is encoded by the cyp19 gene, and functions in complex with NADPH-ferrihemoprotein reductase in the cytochrome p450 system. Adipose Tissue: Histology inhibitor:
    • Anastrozole Anastrozole A nitrile and triazole derivative that acts as a selective nonsteroidal aromatase inhibitor. It is used in the treatment of estrogen nuclear receptor-positive breast cancer in postmenopausal women. Antiestrogens 1 mg once daily for 5 years
    • Off-label use for breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer risk reduction
    • Used in postmenopausal women

Surgical: prophylactic mastectomy Mastectomy Surgical procedure to remove one or both breasts. Fat Necrosis of the Breast:

Women should be counseled on the potential morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status of surgical procedures ( surgical menopause Surgical Menopause Menopause, libido, body image).

• Indications:
  • BRCA1 or BRCA2 carriers Carriers The Cell: Cell Membrane
  • Other genetic mutations Genetic Mutations Carcinogenesis that carry a greater lifetime risk for developing breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
• Does not completely eliminate the risk of cancer
• May be done in conjunction with salpingo-oophorectomy to reduce ovarian cancer Ovarian cancer Ovarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer risk

Screening for Special Populations

Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with dense breast tissue^[3,7]

• The same approach to screening Screening Preoperative Care is recommended.
• Digital mammography Digital Mammography Breast Cancer Screening is preferred over film.
• ASBrS and the European Commission both recommend DBT for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with dense breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy.^[3,7]
• If there are no additional risk factors, no supplemental screening Screening Preoperative Care is recommended.
• MRI or US may be used as an adjunct in moderate- or high-risk patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship.

Transgender Transgender Persons having a sense of persistent identification with, and expression of, gender-coded behaviors not typically associated with one’s anatomical sex at birth, with or without a desire to undergo sex reassignment procedures. Gender Dysphoria patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship^[16]

• Mammography Mammography Radiographic examination of the breast. Breast Cancer Screening screening Screening Preoperative Care is typically appropriate in the following patient populations:
  • Transgender Transgender Persons having a sense of persistent identification with, and expression of, gender-coded behaviors not typically associated with one’s anatomical sex at birth, with or without a desire to undergo sex reassignment procedures. Gender Dysphoria women (male-to-female) at high risk for breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer who are 25‒30 years of age with past or current hormone use ≥ 5 years 
  • Transgender Transgender Persons having a sense of persistent identification with, and expression of, gender-coded behaviors not typically associated with one’s anatomical sex at birth, with or without a desire to undergo sex reassignment procedures. Gender Dysphoria men (female-to-male) with reduction mammoplasty or no chest surgery who are:
    • At high risk for breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer and 25‒30 years of age 
    • At intermediate risk for breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer and ≥ 30 years of age 
    • At average risk for breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer and ≥ 40 years of age 
• Mammography Mammography Radiographic examination of the breast. Breast Cancer Screening may be appropriate in some of the following cases:
  • Transgender Transgender Persons having a sense of persistent identification with, and expression of, gender-coded behaviors not typically associated with one’s anatomical sex at birth, with or without a desire to undergo sex reassignment procedures. Gender Dysphoria women at high risk who are 25‒30 years of age with hormone use < 5 years
  • Transgender Transgender Persons having a sense of persistent identification with, and expression of, gender-coded behaviors not typically associated with one’s anatomical sex at birth, with or without a desire to undergo sex reassignment procedures. Gender Dysphoria women at average risk who are ≥ 40 years of age with past or current hormone use ≥ 5 years
• Mammography Mammography Radiographic examination of the breast. Breast Cancer Screening is typically not indicated for:
  • Transgender Transgender Persons having a sense of persistent identification with, and expression of, gender-coded behaviors not typically associated with one’s anatomical sex at birth, with or without a desire to undergo sex reassignment procedures. Gender Dysphoria women at average risk with hormone use < 5 years at any age.
  • Transgender Transgender Persons having a sense of persistent identification with, and expression of, gender-coded behaviors not typically associated with one’s anatomical sex at birth, with or without a desire to undergo sex reassignment procedures. Gender Dysphoria men with bilateral mastectomies at any age and any risk level

Male BRCA carriers Carriers The Cell: Cell Membrane^[19,24]

Male BRCA carriers Carriers The Cell: Cell Membrane have a higher risk for breast, prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. , and pancreatic cancers:

• Monthly breast self-examination starting at age 35
• Annual clinical breast exam starting at age 35
• Annual mammography Mammography Radiographic examination of the breast. Breast Cancer Screening can be considered in men with gynecomastia Gynecomastia Gynecomastia is a benign proliferation of male breast glandular ductal tissue, usually bilateral, caused by increased estrogen activity, decreased testosterone activity, or medications. The condition is common and physiological in neonates, adolescent boys, and elderly men. Gynecomastia or increased breast density (evidence is limited).
• Prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer screening Screening Preoperative Care starting at age 40 for BRCA2 carriers Carriers The Cell: Cell Membrane
• Consideration of prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. screening Screening Preoperative Care starting at age 40 for BRCA1 carriers Carriers The Cell: Cell Membrane