for Breast Cancer Screening:

Update 2003

Robert A. Smith, PhD; Debbie Saslow, PhD; Kimberly Andrews Sawyer;Wylie Burke,MD, PhD

(for the High-Risk Work Group); Mary E. Costanza, MD (for the Screening Older Women Work

Group);W. Phil Evans III, MD (for the Mammography Work Group); Roger S. Foster, Jr.,MD

(for the Physical Examination Work Group); Edward Hendrick, PhD (for the New Technologies

Work Group); Harmon J. Eyre,MD; Steven Sener, MD (for the Breast Cancer Advisory Group)

ABSTRACT In 2003, the American Cancer Society updated its guidelines for early detection

of breast cancer based on recommendations from a formal review of evidence and a recent

workshop. The new screening recommendations address screening mammography, physical

examination, screening older women and women with comorbid conditions, screening

women at high risk, and new screening technologies. (CA Cancer J Clin 2003;54:141-169.)

© American Cancer Society, 2003.

INTRODUCTION

The underlying premise for breast cancer screening is that it allows for the

detection of breast cancers before they become palpable. Breast cancer is a

progressive disease, and small tumors are more likely to be early stage disease, have a

better prognosis, and are more successfully treated.1 In this document, we use the

term screening to refer to the testing of asymptomatic individuals for the detection of

occult disease. Early detection means the application of a technique or strategy that

results in earlier diagnosis of nonpalpable, as well as palpable, breast cancers than

otherwise would have occurred.

The efficacy of breast cancer screening has been demonstrated in randomized

controlled trials (RCTs) and observational studies; thus, most organizations that issue

recommendations endorse regular mammography as an important part of preventive

care.However, while it is true that screen-detected breast cancers are associated with

reduced morbidity and mortality, the majority of women who participate in

screening will not develop breast cancer in their lifetime. Screening also will not

benefit all women who are diagnosed with breast cancer, and it leads to harms in

women who undergo biopsy for abnormalities that are not breast cancer, as well as

those who are overtreated for ductal carcinoma in situ (DCIS) that might have been

nonprogressive. Thus, in addition to benefits, limitations of screening and harms

associated with screening are addressed in this guideline update.

Author disclosures: Dr. Runowicz receives speaking fees and research support from Cytyc Corporation (First

Cyte Ductal Lavage). Dr. Rubinstein is on the speaker’s bureau for Myriad Genetic Laboratories, Inc. Dr. D’Orsi is

a medical consultant to GE Medical Systems and R2 Technology, Inc. Dr. Feig is on the medical advisory board of

R2 Technology, Inc., a company that sells a computer-aided detection device for mammography; he does not receive

any financial remuneration or grant support from the company. Dr. Giger is a shareholder in R2 Technology, Inc.;

she also has received unrestricted research support from the company in the past.

In 1997, the American Cancer Society

(ACS) updated its guidelines for breast cancer

screening.2 The most notable change in the

1997 guideline update was the recommendation

that women should begin annual

screening at age 40; the previous guideline had

recommended mammography every one to

two years for women beginning at age 40, and

annual mammography for women beginning at

age 50.3 The 1997 update also noted that there

was no chronological age at which screening

should stop, emphasizing that as long as a

woman was in good health she likely

would benefit from breast cancer screening.

Recommendations for clinical breast examination

(CBE) were modified by adding the

advice that women 40 and older schedule

annual CBE close to the time of, and before,

their annual mammograms.2

Guideline Development

In 2002, the ACS convened an expert panel

to review the existing early detection guidelines

based on evidence that has accumulated since

the last revision. The panel was divided into

work groups to review recent evidence and

develop recommendations regarding: (1)

mammography; (2) physical examination; (3)

screening of older women and women with

comorbid conditions; (4) screening high-risk

women; and (5) screening with new technologies.

During the current guideline review,

literature related to breast cancer screening

published between January 1997 and

September 2002, including new screening tests,

was identified using MEDLINE (National

Library of Medicine), bibliographies of

identified articles, personal files of panel

members, and unpublished manuscripts. Expert

panel members reviewed articles using specified

criteria and discussed them during a series of

conference calls. Each work group developed

recommendations, rationale, and evidence

summaries, and reviewed the summaries developed

by the other work groups prior to a

September 2002 workshop. When evidence

was insufficient or lacking, the final

recommendations incorporated the expert

opinions of the panel members. During the

conference calls and workshop, consensus was

reached on the key issues within the guideline

recommendations. Following the workshop,

ACS Breast Cancer Advisory Group members

deliberated over the guideline modifications.

Each work group member and workshop

attendee was given the opportunity to review

the draft of this manuscript. Numerous

professional, advocacy, and governmental

organizations also were invited to review the

draft guidelines.

RECOMMENDATIONS, RATIONALE, AND EVIDENCE

Summary of Guidelines

A summary of the update of the ACS

guidelines for early breast cancer detection is

shown in Table 1.

SCREENING WITH MAMMOGRAPHY

Recommendation

Women at average risk should begin annual

mammography at age 40.Women should have

an opportunity to become informed about

the benefits, limitations, and potential harms

associated with regular screening.

Rationale and Evidence

Since 1997, there have been updates in

the evidence from RCTs of breast cancer

screenings. Several other reports have

challenged the value of screening for breast

cancer with mammography,4-7 leading to a surge

of new literature reexamining the underlying

updated clinical trial results from individual studies

and meta-analyses continue to show a significant

mortality reduction from mammography screening,

and this finding is further supported by evidence

from organized screening programs.