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Breast Exams
Causes of Breast Cancer
Early Detection of Breast Cancer
Mammogram Information
Paying for Breast Exam Screening
Signs and Symptoms of Breast Cancer
Recommendations for People Who Do Not Have Breast Cancer

Breast Cancer prevention recommendations for people without symptoms



American Cancer Society recommendations for early breast cancer detection in women without breast symptoms

Women age 40 and older should have a mammogram every 

year and should continue to do so for as long as they are in good health.

  • Current evidence supporting mammograms is even stronger than in the past. In particular, recent evidence has confirmed that mammograms offer substantial benefit for women in their 40s. Women can feel confident about the benefits associated with regular mammograms for finding cancer early. However, mammograms also have limitations. A mammogram can miss some cancers, and it may lead to follow up of findings that are not cancer.
  • Women should be told about the benefits and limitations linked with yearly mammograms. But despite their limitations, mammograms are still a very effective and valuable tool for decreasing suffering and death from breast cancer.
  • Mammograms should be continued regardless of a woman's age, as long as she does not have serious, chronic health problems such as congestive heart failure, end-stage renal disease, chronic obstructive pulmonary disease, and moderate to severe dementia. Age alone should not be the reason to stop having regular mammograms. Women with serious health problems or short life expectancies should discuss with their doctors whether to continue having mammograms.

Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a periodic (regular) health exam by a health professional preferably every 3 years. Starting at age 40, women should have a CBE by a health professional every year.

  • CBE is done along with mammograms and offers a chance for women and their doctor or nurse to discuss changes in their breasts, early detection testing, and factors in the woman's history that might make her more likely to have breast cancer.
  • There may be some benefit in having the CBE shortly before the mammogram. The exam should include instruction for the purpose of getting more familiar with your own breasts. Women should also be given information about the benefits and limitations of CBE and breast self-examination (BSE). The chance of breast cancer occurring is very low for women in their 20s and gradually increases with age. Women should be told to promptly report any new breast symptoms to a health professional.

Breast self-examination (BSE) is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away.

  • Research has shown that BSE plays a small role in finding breast cancer compared with finding a breast lump by chance or simply being aware of what is normal for each woman. Some women feel very comfortable doing BSE regularly (usually monthly after their period) which involves a systematic step-by-step approach to examining the look and feel of one's breasts. Other women are more comfortable simply feeling their breasts in a less systematic approach, such as while showering or getting dressed or doing an occasional thorough exam. Sometimes, women are so concerned about "doing it right" that they become stressed over the technique. Doing BSE regularly is one way for women to know how their breasts normally look and feel and to notice any changes. The goal, with or without BSE, is to report any breast changes to a doctor or nurse right away.
  • Women who choose to use a step-by-step approach to BSE should have their BSE technique reviewed during their physical exam by a health professional. It is okay for women to choose not to do BSE or not to do it on a regular schedule such as once every month. However, by doing the exam regularly, you get to know how your breasts normally look and feel and you can more readily find any changes. If a change occurs, such as development of a lump or swelling, skin irritation or dimpling, nipple pain or retraction (turning inward), redness or scaliness of the nipple or breast skin, or a discharge other than breast milk (such as staining of your sheets or bra), you should see your health care professional as soon as possible for evaluation. Remember that most of the time, however, these breast changes are not cancer.

Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15% to 20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%.

Women at high risk include those who:

  • have a known BRCA1 or BRCA2 gene mutation
  • have a first-degree relative (parent, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves
  • have a lifetime risk of breast cancer of 20% to 25% or greater, according to risk assessment tools that are based mainly on family history (see below)
  • had radiation therapy to the chest when they were between the ages of 10 and 30 years
  • have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have one of these syndromes in first-degree relatives

Women at moderately increased risk include those who:

  • have a lifetime risk of breast cancer of 15% to 20%, according to risk assessment tools that are based mainly on family history (see below)
  • have a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH)
  • have extremely dense breasts or unevenly dense breasts when viewed by mammograms

If MRI is used, it should be in addition to, not instead of, a screening mammogram. This is because although an MRI is a more sensitive test (it's more likely to detect cancer than a mammogram), it may still miss some cancers that a mammogram would detect.

For most women at high risk, screening with MRI and mammograms should begin at age 30 years and continue for as long as a woman is in good health. But because the evidence is limited regarding the best age at which to start screening, this decision should be based on shared decision-making between patients and their health care providers, taking into account personal circumstances and preferences.

Several risk assessment tools, with names such as the Gail model, the Claus model, and the Tyrer-Cuzick model, are available to help health professionals estimate a woman's breast cancer risk. These tools give approximate, rather than precise, estimates of breast cancer risk based on different combinations of risk factors and different data sets. As a result, they may give different risk estimates for the same woman. Their results should be discussed by a woman and her doctor when being used to decide whether to start MRI screening.

It is recommended that women who get a screening MRI do so at a facility that can do an MRI-guided breast biopsy at the same time if needed. Otherwise, the woman will have to have a second MRI exam at another facility when she has the biopsy.

There is no evidence right now that MRI will be an effective screening tool for women at average risk. While MRI is more sensitive than mammograms, it also has a higher false-positive rate (it is more likely to find something that turns out not to be cancer). This would lead to unneeded biopsies and other tests in many of the women screened.

The American Cancer Society believes the use of mammograms, MRI (in women at high risk), clinical breast exams, and finding and reporting breast changes early, according to the recommendations outlined above, offers women the best chance to reduce their risk of dying from breast cancer. This approach is clearly better than any one exam or test alone. Without question, a physical exam of the breast without a mammogram would miss the opportunity to detect many breast cancers that are too small for a woman or her doctor to feel but can be seen on mammograms. Mammograms are a sensitive screening method, but a small percentage of breast cancers do not show up on mammograms but can be felt by a woman or her doctors. For women at high risk of breast cancer, such as those with BRCA gene mutations or a strong family history, both MRI and mammogram exams of the breast are recommended.

 

 

 

 

 

 

 

 

 

 

 

 

State Mammography Screening Coverage Laws


State Frequency and Age Requirements
Alabama Every 2 years for 40s or physician recommendation; each year for 50+, or physician recommendation
Alaska Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
Arizona Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
Arkansas Insurers must offer coverage for baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
California Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
Colorado Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
Connecticut Baseline for ages 35-39, every year 40+ (Individual and group insurers are also required to provide coverage for a comprehensive ultrasound screening of the entire breast if it is recommended by a physician for a woman classified as a category 2, 3, 4 or 5 under the American College of Radiology's Breast Imaging Reporting and Data System.)
Washington, DC Coverage
Delaware Baseline for ages 35-39, every 2 years for 40s, each year 50+
Florida Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
Georgia Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
Hawaii Annual for 40+, or physician recommendation
Iowa Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
Idaho Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
Illinois Baseline for ages 35-39, annual for 40+
Indiana Annual for 40+, or physician recommendation
Kansas Covered in accordance with American Cancer Society guidelines if insurers provide reimbursement for lab and X-ray services
Kentucky Baseline for ages 35-39, every 2 years for 40s, each year 50+
Louisiana Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
Massachusetts Baseline for ages 35-39 and annual for 40+
Maryland Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
Maine Annual for 40+
Michigan Insurance must offer or include coverage of baseline for ages 35-39, annual for 40+
Minnesota If recommended
Missouri Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
Mississippi Insurance must offer annual for ages 35+
Montana Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
North Carolina Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
North Dakota Baseline for ages 35-39, annual for 40+, or physician recommendation.
Nebraska Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
New Hampshire Baseline for ages 35-39, every 2 years for 40s, each year 50+
New Jersey Baseline for ages 35-39, each year for 40+
New Mexico Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
Nevada Baseline for ages 35-39, and annual for 40+
New York Baseline for ages 35-39, every year for 40+, or physician recommendation
Ohio Baseline for ages 35-39, every 2 years for 40s, every year if a woman is at least 50 but under 65, or physician recommendation
Oklahoma Baseline for ages 35-39, and annual for 40+
Oregon Annual for 40+, or by referral
Pennsylvania Annual for 40+, physician recommendation. for under 40
Rhode Island According to ACS guidelines (Also requires individual and group insurers to provide coverage for 2 screening mammograms per year for women who have been treated for breast cancer within the past 5 years or who are at high risk for developing cancer due to genetic predisposition, have a high-risk lesion from a prior biopsy or atypical ductal hyperplasia)
South Carolina Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation, in accordance with American Cancer Society guidelines
South Dakota Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
Tennessee Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation
Texas Annual for 35+
Utah None
Virginia Baseline for ages 35-39, every 2 years for 40s, each year 50+
Vermont Annual for 50+, physician recommendation for under 50
Washington If recommended
Wisconsin 2 exams total for ages 45-49, each year 50+
West Virginia Baseline for ages 35-39, every 2 years for 40s
Wyoming Covers a screening mammogram and clinical breast exam along with other cancer screening tests; however, the health plan is responsible only up to $250 for all cancer screenings

Sources: Health Policy Tracking Service, " Mandated Benefits: Breast Cancer Screening Coverage Requirements," 4/01/04; CDC Division of Cancer Prevention and Control "State Laws Relating to Breast Cancer: Legislative Summary, January 1949 to May 2000."
Health Policy Tracking Service, "Overview: Health Insurance Access and Oversight," 6/20/05
Netscan's Health Policy Tracking Service Health Insurance Snapshot, 8/8/05
Netscan's Health Policy Tracking Service, "Mandated Benefits: An Overview of 2006 Activity," 4/3/06

Updated 9/14/06, ACS National Government Relations Department

Other state efforts and self-insured plans

Other types of health coverage also provide screening mammograms. Public employee health plans are governed by state regulation and legislation, and many cover screening mammograms. Self-insured plans are not regulated at the state level, which means women in these plans do not necessarily get screening mammogram benefits, even if there are laws in the state to cover such benefits. Self-insured plans are typically large employers. Women who have self-insured-based health insurance should check with their health plans to see what breast cancer early detection services are covered.

Medicaid

All state Medicaid programs plus the District of Columbia cover screening mammograms. This coverage may or may not conform to American Cancer Society guidelines. State Medicaid offices should be able to provide screening coverage information to interested individuals. The Medicaid programs are governed by state legislation and regulation, so assured coverage is not always apparent in legislative bills.

In addition, all 50 states plus the District of Columbia have opted to provide Medicaid coverage for all women diagnosed with breast cancer through the Centers for Disease Control and Prevention's (CDC's) National Breast and Cervical Cancer Early Detection Program (see the next section), so that they may receive cancer treatment. This option allows states to receive significant matching funds from the federal government. States vary in the age, income and other requirements that women must meet in order to qualify for treatment through the Medicaid program. (All 50 states, 4 U.S. territories, the District of Columbia, and 13 American Indian/Alaska Native organizations participate in the National Breast and Cervical Cancer Early Detection Program.)

National Breast and Cervical Cancer Early Detection Program

States are making breast cancer screening more available to medically underserved women through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). This program provides breast and cervical cancer screening to low-income, uninsured, and underserved women for free or at very low cost. The NBCCEDP attempts to reach as many women in medically underserved communities as possible, including older women, women without health insurance, and women who are members of racial and ethnic minorities. Age and income requirements vary by state.

The program provides both screening and diagnostic services, including:

  • clinical breast exams
  • mammograms
  • Pap tests
  • diagnostic testing for women whose screening results are abnormal
  • surgical consultations
  • referrals to treatment

Though the program is administered within each state, tribe, or territory, the Centers for Disease Control and Prevention (CDC) provides matching funds and support to each program.

Since 1991 when the program began, it has provided more than 7.8 million screening exams to underserved women and diagnosed more than 35,000 breast cancers, more than 114,000 pre-cancerous cervical lesions, and more than 2,100 cervical cancers. Now that the program is firmly established, doctors are detecting new cancers at their earliest stages, leading to longer-term survival. These accomplishments demonstrate a truly nationwide effort. Unfortunately, however, due to limited resources, only about 1 in 5 eligible women aged 40 to 64 is served nationwide.

As noted above, all 50 states plus the District of Columbia have opted to provide Medicaid coverage for women diagnosed with breast cancer through the NBCCEDP, so that they may receive cancer treatment.

Each state's Department of Health will have information on how to contact the nearest CDC screening and early detection program in your area. For more information, please contact the CDC at 1-800-CDC-INFO ( 1-800-232-4636) or through their web site at www.cdc.gov/cancer.

Medicare

Since 1998, Medicare has covered mammograms once every 12 months for all women with Medicare aged 40 and over. (Women are eligible for Medicare if they are age 65 and older, are disabled, or have end-stage renal disease.) Medicare also pays for a clinical breast exam once every 24 months along with a pelvic exam. These benefits are not subject to the usual Medicare Part B deductible, but the standard 20% co-pay applies.

Medicare also covers an initial preventive physical exam for all new Medicare beneficiaries within 6 months of enrolling in Medicare. The "Welcome to Medicare" exam includes measurements of height, weight, and blood pressure, in addition to referrals for prevention and early detection services already covered under Medicare, such as mammograms.

Additional resources

More information from your American Cancer Society

The following information may also be helpful to you. These materials may be ordered from our toll-free number, 1-800-227-2345, or found on our Web site, www.cancer.org.

  • Breast Cancer Dictionary (also available in Spanish)

National organizations and web sites*

In addition to the American Cancer Society, other sources of patient information and support include:

Centers for Disease Control and Prevention (CDC)
Cancer Prevention and Control Program
Toll-free number: 1-800-232-4636 (1-800-CDC-INFO)
Web site: www.cdc.gov/cancer
Information about the National Breast and Cervical Cancer Early Detection Program

National Cancer Institute (NCI)
Toll-free number: 1-800-4-CANCER (1-800-422-6237)
Web site: www.cancer.gov
General breast cancer information

*Inclusion on this list does not imply endorsement by the American Cancer Society.

No matter who you are, we can help. Contact us any time, day or night, for information and support. Call us at 1-800-227-2345 or visit www.cancer.org.

References

American Cancer Society. Detailed Guide: Breast Cancer. 2009. Available at: www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=5. Accessed September 22, 2009.

Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program. Available at: www.cdc.gov/cancer/nbccedp/about.htm. Accessed September 22, 2009.

Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 2005;353:17731783.

Saslow D, Boetes C, Burke W, et al for the American Cancer Society Breast Cancer Advisory Group. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57:7589.

Smith RA, Saslow D, Sawyer KA, et al. American Cancer Society guidelines for breast cancer screening: Update 2003. CA Cancer J Clin. 2003;53:141169.

 

Source: American Cancer Society


Note: Some statements in this article may not be approved by the FDA. This article is for informational purposes only and should not be taken as professional medical advice.

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