What’s next: Incorporate routine risk assessment into clinical practice
It is not time to abandon screening mammography for all women in their 40s. Rather, routine risk assessment should be performed using one of many available validated or widely tested tools, a recommendation supported by the American College of Obstetricians and Gynecologists, the National Comprehensive Cancer Network, and the US Preventive Services Task Force.5,6,12
Ideally, these tools can be incorporated into an electronic health record and prepopulated using already available patient data (such as age, reproductive risk factors, current medications, breast density if available, and family history). Prepopulating available data into breast cancer risk calculators would allow clinicians to spend time on counseling women regarding breast cancer risk and appropriate screening methods. The TABLE provides a summary of useful breast cancer risk calculators and includes comments about their utility and significant limitations and benefits. In addition to breast cancer risk, the more comprehensive risk calculators (Tyrer-Cuzick and BOADICEA) allow calculation of ovarian cancer risk and gene mutation risk.
Routinely performing breast cancer risk assessment can guide discussions of screening mammography and can provide data for conducting a more individualized discussion on cancer genetic counseling and testing, risk reduction methods in high-risk women, and possible use of intensive breast cancer screening tools in identified high-risk women.
Ultimately, debating the question of whether all women should have routine breast cancer screening in their 40s should be passé. Ideally, all women should undergo breast cancer risk assessment in their 20s. Risk assessment results can then be used to guide the discussion of multiple potential interventions for women in their 40s (or earlier if appropriate), including routine screening mammography, cancer genetic counseling and testing in appropriate individuals, and intervention for women who are identified at high risk.
Absent breast cancer risk assessment, screening mammography still should be offered to women in their 40s, and the decision to proceed should be based on a discussion of risks, benefits, and the value the patient places on these factors.●