Breast Cancer Screening - NCCN

Breast Cancer Screening and Diagnosis Version 3.2018. (2018).

 Take Aways
- Imaging for women < 30 yo starts with US. >30 yo usually gets both US and mammo
- follow NCCN guidelines

 ----

 General
- average lifetime risk for breast cancer in a woman in the US is about 12.3%
- 16% of women will have sx to a provider (breast mass or pain)

 Diagnostic Imaging after Screening Mammo Recall
- diagnostic mammo has higher sensitivity but lower specificity vs screening mammo
- BIRADS scoring
> BIRADS 1: negative findings - routine screening recommended
> 2: benign - routine screening recommended
> 3: probably benign - diagnostic mammo at 6 mo, then 6-12 mo for 1-2 yrs (caveat, if strong FH, then biopsy)
> 4: suspicious for malignancy - tissue diagnosis (core needle Bx or needle localization excisional bx). Then check concordance
> 5: highly suggestive of malignancy - tissue diagnosis. Then check concordance
> 6: proven malignancy - see guidelines for breast cancer treatment

 Breast tissue bx
- Fine Needle Aspiration bx: minimally invasive, low cost, but will likely need follow up tissue bx if atypia/malignancy noted
- Core needle bx: obtain multiple cores, usually with imaging guidance or palpation. better accuracy than FNA and better ability to get sufficient tissue
- Excisional bx - much more invasive. Recommended if core needle bx is indeterminate, discordant benign lesion, atypical ductal hyperplasia, or other pathology concerns

Palpable mass in breast:
- if <30 yo, much less suspicious for cancer. Start with US.
- if >30 yo, go straight to diagnostic mammo and US.
> solid mass - probably benign, so just observe. Or can get tissue if mass looks suspicious
> cystic mass - 1. simple: benign, 2. complicated - looks similar to simple cyst with maybe debris, low risk for cancer <2% so either aspirate or short term f/u with US, or 3. complex: high risk malignancy 14-23%. Get tissue

 Nipple discharge
- most concerning if discharge is persistent, reproducible, spontaneous, unilateral, serous, sanguineous, or serosanguinous.
- if no palpable mass, and <40 yo, then observe (until it is persistent)
- if >40 yo regardless of palpable mass, then mammo is next step
NCCN also provides multiple pages of a diagnostic algorithm for diagnosing breast cancer with symptoms.

 Asymmetrical Thickening/Nodularity
- similar diagnostic algorithm to that of a palpable mass

Skin changes
- highly consider Inflammatory Breast Cancer (IBC) if peau d'orange and erythema present
> IBC is 1-6% of breast cancer, very aggressive, needs 1/3+ skin of breast with erythema and skin changes
- consider Paget's if nipple exoriation, scaling, and eczema present
> see neoplastic cells in epidermis of nipple areolar complex. lots of eczema of the nipple. needs a skin bx for diagnosis
- start with b/l diagnostic mammo +/- US, then get punch bx of skin/nipple if images negative. Can try abx

 Breast pain
- actually very low sx for cancer only 1.2-6.7%. Do a clinical breast exam. If negative and mammo is negative, give reassurance.

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