CLINICAL PROBLEM |
INVESTIGATION |
RECOMMENDATION |
COMMENT |
||
| Asymptomatic Patients | |||||
| Screening < 40 yrs | J1 | Mammography | Not indicated | [A] | Cancer is uncommon under 35 and the sensitivity of mammography in detecting malignancy can be reduced in younger dense breasts. |
| Screening 40-49 yrs | J2 | Mammography | Not indicated | [A] | Recent evidence indicates that whilst cancers can be diagnosed at screening, benefit to the population of this age group is limited. The outcome of the UKCC 40-49 yrs trial is awaited. |
| Screening 50-64 yrs | J3 | Mammography | Indicated | [A] | Decreased mortality is proven with
regular screening in this age group. The UK NHS Breast Screening Programme (NBSP) operates
by invitation every 3 years. N.B. a single view mammogram gives an average breast dose equivalent of about 2 mGy. The lifetime risk of induction of a lifetime cancer from one such examination in this age group is about 1:50,000. With a survival rate for breast cancer of 50%, the lifetime fatal cancer risk from such a mammographic examination falls to about 1 in 100,000. This risk equates approximately to the lifetime cancer risk arising from the radiation exposure experienced during a return flight from the UK to Australia. A risk of 1 in 100,000 is only slightly greater that the lifetime risk of being struck by lightning. For a two-view per breast mammographic examination the lifetime fatal risk is doubled to 1 in 50,0000. For women aged 40-49 this risk is increased by about 30% (NB: these estimates have been revised in line with advice from the NRPB (B Wall letter 5.1.2000)). Controversy about the correct indications for mammography in different age groups is primarily based upon considerations of clinical benefit, not risk. Although mammography is the best method for detecting early breast cancer, it is not 100% sensitive and a negative study cannot exclude breast cancer. |
| Screening 65 yrs + | J4 | Mammography | Indicated | [A] | Definitely indicated. However self referral to the NBSP is required. |
| Family history of breast cancer | J5 | Mammography | Specialised examination | [C] | At present there is no evidence of benefit but there is some evidence of harm. Screening should only be contemplated after genetic risk assessments and appropriate counselling as to the risks and unproven benefits. Consensus at the moment is that screening should only be contemplated when the lifetime risk of breast cancer is greater than three or four times average. Units should collect and audit their work. This topic is being rigorously discussed at the present time. |
| Women < 50 yrs having or being considered for HRT | J6 | Mammography | Not indicated | [A] | A meta-analysis has shown women <50 yrs who have received HRT for > 11 yrs are not at increased risk of breast cancer compared to a peer group. Women on HRT 50 yrs and over can be appropriately monitored within the NBSP. |
| Augmentation mammoplasty (50 yrs and over) | J7 | Mammography | Indicated | [C] | As part of the NBSP - best performed at a static unit as there may be a need for extra views or US. |
| Symptomatic Patients | |||||
| Clinical suspicion of carcinoma | J8 | Mammography | Indicated | [B] | Referral to a breast clinic should precede any radiological investigation. |
| US | Specialised investigation | [B] | Mammography +/- US should be used in the context of triple assessment - i.e. clinical examination, imaging & cytology/biopsy. | ||
| Generalised lumpiness, generalised breast pain, or tenderness, or longstanding nipple retraction | J9 | Mammography or US | Not indicated | [C] | In the absence of other signs suggestive of malignancy, imaging is unlikely to influence management. Focal, rather than generalised pain may warrant investigation. |
| Cyclical mastalgia | J10 | Mammography | Not indicated | [B] | In the absence of other clinical signs suggestive of malignancy and localised pain, investigation is unlikely to influence management. |
| Augmentation mammoplasty | J11 | US MRI |
Indicated Specialised investigation | [B] [B] |
The assessment of integrity of breast implants or coincident masses requires specialist skills and facilities. |
| Paget's disease of the nipple | J12 | Mammography | Indicated | [C] | The prevalence of coexistent breast cancer varies in published studies, but its association is clear and justifies specialist referral. |
| Breast inflammation | J13 | US | Indicated | [B] | US can distinguish between an abscess requiring drainage and diffuse inflammation, and can guide aspiration when appropriate. Mammography may be of value where malignancy is possible. |