How do I screen patients for breast cancer?

Breast cancer is a complex, heterogeneous disease. Approximately 230,000 women are diagnosed with breast cancer in the United States each year and approximately 40,000 women die each year with breast cancer. Although prevention of the disease would be preferred, no real prospects are available in the near future that would be applicable to the majority of women who are at risk for breast cancer. Early detection remains an effective way to decrease mortality from breast cancer, treating it at an early stage when it is likely curable. Unfortunately, screening does have its limitations. Not all breast cancers can be identified with routine screening. Some breast cancers despite early detection still result in poor outcomes. Furthermore, false-positive results are not infrequently seen in women undergoing screening mammography. Most patients experience significant anxiety when called back for additional studies or a biopsy. Not to mention the additional cost and potential side effects and complications of invasive procedures. In addition, there are breast cancers that may be indolent and otherwise not a threat to patients. In fact, some studies show that up to one quarter of cancers detected by screening may represent overdiagnosis. Currently, however, there are no proven methods to discern with complete certainty the cancers that would progress to lethal disease from those that would not. Women should be counseled regarding the risks and benefits of screening. Women at average risk should initiate screening mammography annually at the age of 40 years. Women at significant increased risk for breast cancer should be screened earlier. MRI has been shown to increase detection of breast cancer in women at increased risk and should be used as an adjunct to mammography in this high-risk patient population.