J
J. Breast disease 

CLINICAL/DIAGNOSTIC

PROBLEM

INVESTIGATION

RECOMMENDATION

(GRADE) 

COMMENT

DOSE
Asymptomatic patients
Screening women < 40 years old Mammography Not indicated (B) There is no evidence to support screening of women < 40 years old who are not at increased risk of breast cancer. I
 
Screening women 40-49 years old Mammography Indicated only in specific circumstances (A) Women seeking screening at this age should be made I aware of the risks and benefits. I
US Indicated only in specific circumstances (B) Useful adjunct to mammography in women with dense breasts and those with implants. 0
 
Screening women 50-64 years old Mammography Indicated (A) Women aged 50-64 are invited for screening at 3-yearly intervals in the UK under the auspices of the NHS Breast Screening Programme. I
US Indicated only in specific circumstances (B) Useful adjunct to mammography in women with dense breasts and those with implants. 0
 
Screening women > 65 years old Mammography Indicated (A) Currently self-referral to the NHS Breast Screening Programme is required, but screening by invitation is being extended up to age 70 by 2005. I
US Indicated only in specific circumstances (B) Useful adjunct to mammography in women with dense breasts and those with implants. 0
 
Family history of breast cancer Mammography Specialised investigation (B) Evidence of benefit is emerging for women at significantly increased risk in their 40s and appears to outweigh the harm of screening. Screening should only be undertaken after genetic risk assessments and appropriate counseling as to the risks and benefits. Consensus is that screening of women < 50 years old with a family history should only be undertaken when the lifetime risk of breast cancer is greater than twice the average. Further guidelines for mammographic and other forms of screening in these  women remain under review. I
US Indicated only in specific circumstances (B) Useful adjunct to mammography in women with dense breasts and those with implants. 0
 
Women < 50 years old having or being considered for HRT Mammography Indicated only in specific circumstances (C) HRT has been shown to increase density and benign changes within the breast. There is a subsequent fall in sensitivity and specificity and an increased recall rate from screening. There is no evidence for routine mammography prior to starting HRT. I
US Indicated only in specific circumstances (B) Useful adjunct to mammography in women with dense breasts and those with implants. 0
 
Breast screening in women aged 50 and over who have had augmentation mammoplasty Mammography Indicated (C) Sensitivity for cancer detection lower than in the non-augmented I
US Indicated only in specific circumstances (B) Useful adjunct to mammography in women with dense breasts and those with implants. 0
 
Symptomatic patients
Clinical suspicion of carcinoma Mammography Indicated (B) Referral to a breast clinic should precede any radiological investigation.  Mammography and US should be used in the context of triple assessment (i.e. mammography, US, and needle tests). I
US Indicated (B) Mammography is appropriate for women . 35 years old. For women < 35 years old, US is the imaging investigation of first choice. Performed in the context of triple assessment at a specialist breast clinic. 0
NM Indicated only in specific circumstances (A) Scintimammography is to be performed only if additional information is required after triple assessment, e.g. if there is a disagreement between imaging and pathology. III
MRI Indicated only in specific circumstances (B) To be performed only if additional information is required after triple assessment, e.g. if there is a disagreement between imaging and pathology. 0
 
Augmentation mammoplasty (clinical suspicion of carcinoma) Mammography Indicated (B) Mammography is indicated when there is clinical suspicion of carcinoma in women with implants. I
 
Generalised lumpiness, pain or tenderness, long standing nipple retraction Mammography Not indicated initially (C) May be worthwhile in women > 40 years old with persisting non-suspicious breast symptoms I
US Indicated only in specific circumstances (C) In the absence of other signs suggestive of  malignancy, breast US is unlikely to influence management. 0
 
Cyclical mastalgia Mammography Not indicated (B) Should not be performed in women with breast pain in the absence of clinical signs. I
US Not indicated (B)   0
 
Assessment of integrity of silicon breast implants US and MRI Specialised investigation (B) US is quick and simple and a normal US study is highly predictive of an intact implant. Symptomatic women with implants > 10 years old and positive US have a 94% probability of rupture. MRI can reasonably be used for confirmatory testing in other subsets. 0 + 0
 
Suspected Paget's disease of the nipple Mammography Indicated (C) Mammography will show an abnormality in 50% of women. It is helpful to determine the possibility of image-guided biopsy. When invasive disease is confirmed it will influence the surgical management of the axilla I
 
Breast inflammation Mammography Specialised investigation (C) Helps to diagnose or exclude malignancy when there is clinical doubt. I
US Indicated (C) Also useful in drainage and follow-up 0
 
Breast cancer follow-up (surveillance) Mammography/US/MRI/NM Indicated (A) Mammography, US, and MRI may all be used for follow-up of the conserved breast. In suspected locoregional recurrence the principles of triple assessment apply. Occasionally, scintimammography may have a role. I/0/

0/III
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