Breast Cancer: Risk, Screening, Detection

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Headshot of Jaime Bowman, MD · Vice Chair, Family Medicine
Jaime Bowman
MD · Vice Chair, Family Medicine
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Headshot of Dawn Kopp, Assistant Professor, Vice-Chair—OB/GYN
Dawn Kopp
Assistant Professor, Vice-Chair—OB/GYN
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Table of Contents

Disclosures

No conflicts to disclose.

Case Study: Sam

Sam is a 45-year-old who presents to inquire about their breast cancer risk and when to begin mammography. She has no known family history of breast or ovarian cancer. Menarche was at age 13. Her first child was born when she was 27, and she was briefly on hormonal birth control for three years at age 20. She drinks alchohol 2–3 times a week, usually one glass of wine per sitting. She denies radiation exposure. Her BMI is 34.

Sam Pre-Question
Which risk factors does Sam have that may increase her risk of breast cancer?
a. Age, family history, age at menarche.
b. Radiation exposure, age at first child, and hormonal contraception.
c. Gender, hormonal contraception, BMI.
d. Family history, age at first child, alcohol use.
Sam Pre-Question
According to the U.S. Preventative Task Force, which of the of these screening tools is evidence based to reduce death from breast cancer?
a. Breast self-exam.
b. Screening mammography.
c. Breast ultrasound.
d. Clinical breast exam by provider.
Sam Pre-Question
According to the U.S. Preventative Task Force, when should Sam begin screening mammography, and how often should she be screened?
a. Now, every year.
b. Age 50, every other year.
c. Now, every other year.
d. Should have started at age 40, every year.

Breast anatomy review

breast-anatomy-review-diagram
  • Variations in lobules, lobes based on hormones.
    • Developmental stages.
    • Pregnancy.
    • Exogenous.
  • Lymphatic drainage into axillary and clavicular nodes.
  • Suspension of Cooper’s ligaments and fibrous tissue.
  • Ratio of fibrous tissue and fatty tissue changes density on imaging.

Noncancerous breast disease

  • Chest wall:
    • Costochondritis (reproducible pain).
    • Sprains, strains (pectoralis m/m).
    • Fracture (rib, clavicle).
  • Infections:
    • Mastitis (breastfeeding, bacterial vs. fungal).
    • Breast abscess.
  • Trauma:
    • Bruise.
    • Hematoma.
    • Seroma.
  • Skin:
    • Peau d’orange.*
    • Dermatologic conditions.

Breast Cancer Risk

Estrogen exposure

Other breast cancer risk

Screen these patients as you would for their transitioned to gender.

Transgender men: At a lower risk than cis-gendered women.

Transgender women: At a higher risk than cis-gendered men.

Gender non-binary people: Yet unknown.

People with intersex diagnosis: Yet unknown.

Motivational interviewing

Sufficient/convincing evidence

Increase Risk

  • Alcohol consumption.
  • Body fatness (post-menopausal).
  • Adult height (post-menopausal).
  • Any use of oral contraceptive pills (OCP).
  • Age at first child birth.

Decrease risk

  • Lactation.
  • Body fatness (pre-menopausal).

Insufficient/weak evidence

Increase Risk

  • Total dietary fat.
  • Greater birth weight (pre-menopausal).
  • Tobacco smoking.
  • Hormone replacement therapy.

Decrease risk

  • Fruits and vegetables.
  • Physical activity.
  • Consider social determinants of health equity.
  • Consider agency.
  • I am worried about your breast cancer risk, how do you feel about it?
  • What are you already doing to reduce your risk?

What else do you think you could successfully do?

Listen for aligning values, goals, and barriers.

Assessment tools overview

assessment-tools-overview-algorithm
  • Use genetic and nongenetic risk factors to calculate risk.
  • Not universal for all populations.
  • BRCA 1, 2 family hx breast, ovarian CA.
  • Populations: Ashkenazi Jew, Black.
  • Gail Model 1 (only white women).
  • Modified Gail (more inclusive).
  • Care Model (black women).
  • BCSC (adds density risk).
BRCA 1, 2 Assessment Tools
Regression model calculators
regression-model-calculators
  • Gail Model 1 (only white women).
  • Modified Gail (more inclusive).
  • Care Model (black women).
  • BCSC (adds density risk).
    • Personal history.
    • Age.
    • Ethnicity.
    • Family History.
    • Biopsy history.
    • BI-RADS category (on prior mammogram).

Breast cancer screening

Tools for screening

Breast Self Exam

No evidence that self-exams reduce death from cancer.

Clinical Breast Exam

Contributes little to early detection where mammography screening is available; may increase the rate of false positives.

Mammography

Initiates between ages 40 and 50 depending on risk, annual to biannual until 50, annual until 74 or < 10 years of life expected.

Breast cancer detection

breast-cancer-detection-diagnostic-evaluations
Ultrasound

Ultrasound Distinguishes fluid from solid masses.

Diagnostic Mammography

Diagnostic Mammography

  • Thinner slices.
  • Higher resolution.
  • Adjusted planes.
PET/CT/MRI

PET/CT/MRI
Additional imaging at discretion of radiologist, often to improve imaging very dense breasts or for those at high risk.

Biopsy

Biopsy
Histopathology is diagnostic.

  • Fine needle aspiration.
  • Core biopsy.
  • Tumor resection (nodal dissection).

Source: Science Direct.

Breast screening communication

Interprofessional team challenges

breast-screening-communication-chart-graphic
breast-screening-communication-chart-graph-2

Primary care provider

Radiologist

  • Calculate breast cancer risk.

  • Shared decision with patient on initiating screening.

  • Refer for screening.

  • Communicate normal findings and follow-up intervals.

  • Communicate abnormal findings, answer questions, recommend next steps.

  • Communicate biopsy results, recommend next steps.

  • Refer to surgery, oncology, specialists.

  • Calculate breast cancer risk.

  • Read screening images.

  • Communicate normal findings and follow-up intervals.

  • Communicate abnormal findings, answer questions, recommend next steps.

  • Perform follow-up/additional imaging.

  • Perform biopsy.

  • Communicate biopsy results, recommend next steps.

  • Set screening intervals.

Case Study: Mary
Mary is a 52-year-old G2P2 who is perimenopausal, has no family history of cancer, had a first child at 21, used a copper IUD between children, and underwent tubal after her second birth. Her previous mammogram showed no increased density. Her ethnicity is Mexican on her father's side and black on her mother's side.
1. What is Mary's risk?
2. What is the appropriate screening tool and interval for Mary?
Case Study: Mary
Mary undergoes screening mammography per your recommendation as a low risk but for age of patient. Her mammogram shows an area of increased density without calcifications, and the radiologist recommends further imaging with diagnostic mammography and US. Mary is worried.
1. Who is responsible for supporting Mary and her worry?
2. What happens next?
3. What if Mary declines further imaging?
Case Study: Mary
With your motivational interviewing and counseling, Mary follows up for the additional imaging. Further views show complex, small cysts, and the radiologist offers her the option of repeating imaging in six months or undergoing core biopsy. Now Mary is anxious, and she asks you about genetic testing.
1. Would you recommend Mary for genetic testing? Why or why not?
2. Which options do you recommend and why?
Case Study: Mary
Mary choses to undergo a core biopsy, which the radiologist performs without complication. Results return one week later as a benign adenosis. She may return to annual mammography screening. She is relieved and asks you about breast self-exams.
1. Does adenomyosis change Mary's risk?
2. How do you advise her on breast self-exams?
Case Study: John
John is a 60-year-old cisgendered man with a family history of breast cancer in his mother at age 65. The cancer was advanced at that time, and she passed from the disease. He was recently diagnosed with Hepatitis C after an episode of jaundice and is working on reducing his alcohol intake. His BMI is 35.
Question: Should John be screened?



Question: What is the best screening test for John?



Case Study: Jo
Jo is a 58-year-old transgender woman who is seeing you to taper off of gender affirming estrogen and asks about breast cancer screening. She has taken estrogen for the last 20 years as part of her gender affirmation. She has also undergone breast augmentation, forehead shaping, and a penile inversion vaginoplasty.
Question: When would be/have been the ideal timing to initiate Jo's screening?



Question: Is screening different given Jo's surgeries?



Case Study: Sam

Sam is a 45-year-old who presents to inquire about their breast cancer risk and when to begin mammography. She has no known family history of breast or ovarian cancer. Menarche was at age 13. Her first child was born when she was 27, and she was briefly on hormonal birth control for three years at age 20. She drinks alchohol 2–3 times a week, usually one glass of wine per sitting. She denies radiation exposure. Her BMI is 34.

Sam Answer
Which risk factors does Sam have that may increase her risk of breast cancer?
a. Age, family history, age at menarche.
b. Radiation exposure, age at first child, and hormonal contraception.
c. Gender, hormonal contraception, BMI.
 d. Family history, age at first child, alcohol use.
Sam Answer
According to the U.S. Preventative Task Force, which of the of these screening tools is evidence based to reduce death from breast cancer?
a. Breast self-exam.
b. Screening mammography.
c. Breast ultrasound.
d. Clinical breast exam by provider.
Sam Answer
According to the U.S. Preventative Task Force, when should Sam begin screening mammography, and how often should she be screened?
a. Now, every year.
b. Age 50, every other year.
 c. Now, every other year.
d. Should have started at age 40, every year.

References

  1. Geunwon Kim, MD, PhD, manisha Bahl, MD, MPH, Assessing Risk of Breast Cancer: A Review of Risk Prediction Models, Journal of Breast Imaging, Volume 3, Issue 2, March/April 2021, Pages 144–155.
  2. Breast Cancer in Men. CDC. Accessed November 2023.
  3. de Blok C J M, Wiepjes C M, Nota N M, van Engelen K, Adank M A, Dreijerink K M A et al. Breast cancer risk in transgender people receiving hormone treatment: nationwide cohort study in the Netherlands. BMJ 2019; 365 :l1652 doi:10.1136/bmj.l1652.
  4. What Are the Risk Factors for Breast Cancer? CDC. Accessed November 2023.