A mammogram is an X-ray of the breast. Screening mammography is performed in a woman without breast symptoms in order to detect breast cancer at an early stage when it is most easily treated. Most but not all clinical studies support the role of beginning screening mammography at age 40 for the early detection and treatment of breast cancer. (12,16,17,18) Different groups of experts have reached different conclusions about when mammographic screening should begin and how often it should be performed. The U.S. Preventive Services Task Force recommends that routine screening of average-risk women begin at age 50 and be performed every two years. The American Cancer Society recommends annual screening beginning at age 40.
Breast cancer claims the lives of approximately 40,000 women and is diagnosed in over 200,000 women annually in the United States alone. When diagnosed early, prior to the spread of cancer, breast cancer has a high cure rate. However, once the cancer has spread to distant and/or several sites in the body (advanced stage), cure rates are reduced dramatically. Therefore, regular screening for breast cancer to detect the disease in its earliest stages is imperative to ensure optimal chances for a cure.
This past couples of years has seen a major controversy over the benefit of screening mammograms. Some critics believe that there is no proven survival benefit from screening mammography and that screening leads to over-diagnosis and an increased number of biopsies and surgeries, while other physicians are proponents of mammography and agree that the screening detects earlier cancers and improves survival. Clinical studies have been ongoing in order to determine the definite risks and benefits of screening mammography. Results from these studies indicate that screening mammography does indeed reduce the rate of mortality caused by breast cancer.
Furthermore reducing mammography screening frequency from annually to biennially among women aged 50 to 74 could save the healthcare system billions of dollars annually—and may actually allow physicians to end up screening more women compared with the current practice, according to the results of a study published in the Annals of Internal Medicine.
The recommendation for less frequent screening was based on a rigorous review from the Cancer Intervention and Surveillance Modeling Network—but now researchers are evaluating the cost savings of the approach as well. Researchers developed a computer simulation model to estimate the population-level cost of three U.S. screening strategies in 2010:
- Annual screening (for women aged 40 to 84 years)
- Biennial screening (for women aged 50 to 69 years)
- Screening according to USPSTF guidelines (biennial for those aged 50 to 74 years and personalized based on risk for those younger than 50 years and based on comorbid conditions for those 75 years and older).
The estimated cost of mammography screening in 2010 was $7.8 billion, with approximately 70 percent of women screened. The computer-simulated cost of screening 85 percent of women was:
- Annual Screening: $10.1 billion
- Biennial Screening: $2.6 billion
- USPSTF Guidelines: $3.5 billion
The largest drivers of cost were screening frequency, percentage of women screened, cost of mammography, percentage of women screened with digital mammography, and percentage of mammography recalls.
The researchers concluded that following the USPSTF guidelines would save $4.4 billion and screen 15 percent more women compared with the current screening practices. The guidelines are based on scientific evidence to maximize patient benefit and minimize harm—and they also result in huge cost savings.(19)
Mammographic screening for breast cancer and improved breast cancer treatment have both contributed to declining breast cancer mortality rates in the US, according to a study published in the New England Journal of Medicine . Breast cancer mortality rate has been steadily declining in the US and there has been debate about the cause of this decline and disagreement about the role played by screening mammography.
Settling the question about the contribution of screening mammography to declining mortality rates is important. If women and their physicians are going to continue to adhere to breast cancer screening recommendations, they will need to be confident that screening saves lives.
In order to clarify matters, the National Institutes of Health (NIH) funded seven separate groups in the US to estimate the extent to which treatment and screening have each contributed to the decline in breast cancer mortality. The study involved researchers at the Dana Farber Cancer Institute, Erasmus University, Georgetown University, MD Anderson Cancer Center, University of Rochester, Stanford University, and University of Wisconsin-Madison. Each of the groups developed a different statistical model using the same set of data.
Although there was variability in the estimates, all seven groups drew the same conclusion: The decline in breast cancer mortality that occurred in the US between 1975 and 2000 is explained by a combination of screening and treatment-neither factor alone is responsible. Individual estimates about how much of the decline in mortality is due to screening mammography ranged from 28% to 65%, with a median of 46%. The rest of the decline in mortality was attributed to improved treatment.
The researchers conclude that declining breast cancer mortality is due to both earlier detection of breast cancer through screening mammography, as well as improved cancer treatment. This study provides additional support for the use of screening mammography for the early detection of breast cancer. (15)
Researchers from England recently conducted another clinical study to further evaluate the effects of screening mammography on mortality caused by breast cancer. In this study, the researchers compared two districts in England, the district of Wigan and the district of Manchester. Over 5,000 women 54 years or younger in each district were invited to participate in regular screening mammography. In the district of Wigan, nearly 79% of women had participated, while in the district of Manchester, only 51% of women had participated in several rounds of the screening program. Long-term data indicated that significantly more women in the district of Wigan had been diagnosed with breast cancer; however, significantly more women in the district of Manchester had been diagnosed with advanced stage breast cancer. Long-term survival was greater in the group of women from the district of Wigan, compared to those from the district of Manchester (2.46 versus 4.31 deaths per 10,000 person years).
The researchers concluded that these results provide further evidence clearly indicating that regular screening mammography provides an earlier diagnosis of breast cancer and reduces mortality in women 54 years or younger. All women should speak with their healthcare provider about scheduling regular mammograms and the risks and benefits of routine screening mammography.(1)
Researchers from Sweden evaluated screening mammography and long-term outcomes of from over 200,00 women evaluated over the course of over 20 years. The data published in The Lancet indicated women who participated in a screening program initiated in 1978 involving mammography were less likely to die from breast cancer than their counterparts who did not participate in the screening program. After accounting for several variables such as treatment advances over the 20 years and the fact that screened women may tend to be healthier, researchers found that the reduction of deaths due to breast cancer was still 28% lower in the group of women participating in regular screening mammography.
The researchers concluded that screening mammography significantly reduces the risk of death due to breast cancer in women 40 to 69 years of age. Women between the ages of 40 and 69 may wish to speak with their physician about scheduling for screening mammography.(2)
Age and Screening Mammography
The performance of screening mammography is known to vary by age. Younger women are less likely than older women to have breast cancer, and more likely to experience some of downsides of screening such as false-positive test results. This has made it challenging to identify the optimal age at which screening should begin. The U.S. Preventive Services Task Force recommends that routine screening of average-risk women begin at age 50. The American Cancer Society recommends that screening begin at age 40.
Biennial Mammography is Appropriate for Women Ages 50-74
Women ages 50 to 74 who undergo mammography screening every other year have a similar risk of advanced-stage disease and a lower cumulative risk of false-positive results than those who get mammograms every year. (14) Different groups of experts have reached different conclusions about when mammographic screening should begin and how often it should be performed. In 2009, the U.S. Preventive Services Task Force (USPSTF) issued guidelines recommending that routine screening of average-risk women begin at age 50 and be performed every two years. A number of other groups, including the American Cancer Society, the American College of Radiology, the American Congress of Obstetricians and Gynecologist, and the American Medical Association, recommend annual screening beginning at age 40.
Currently, mammography is the most reliable tool for screening the general population for breast cancer; however, the screening tool does have its limitations—which can include false-positive test results (a suggestion that cancer may be present when it is not); false-negative results (missed cancers); and over diagnosis (resulting in unnecessary treatment). Put simply—over diagnosis is the diagnosis of something that would not have resulted in clinical symptoms in a person’s lifetime.
Because age is not the only risk factor for breast cancer, researchers sought to determine whether the risks and benefits of screening differ according to age, breast density, and postmenopausal hormone therapy use. They analyzed data collected between 1994 and 2008 from the Breast Cancer Surveillance Consortium (BCSC) mammography registries. The study sample included 11,474 women with breast cancer and 922,624 without.
The analysis indicated that biennial versus annual mammography for women ages 50 to 74 was not associated with an increased risk of advanced-stage or large-size tumors regardless of a women’s breast density or hormone therapy use. In contrast, among women ages 40 to 49 with extremely dense breasts, biennial mammography was associated with an increased risk of advanced-stage cancer and large tumors. However, the data also indicated that the cumulative probability of a false-positive result was high among women with extremely dense breasts undergoing annual mammography who were either ages 40 to 49 or who used combination (estrogen plus progesterone) hormone therapy. The risk of false-positives was lower among women ages 50 to 74 with dense breasts who underwent biennial or triennial mammography.
The researchers concluded that women ages 50 to 74 are safe undergoing biennial mammography, regardless of breast density or hormone therapy use because it does not increase the risk of advanced disease, but does substantially reduce the cumulative risk of false-positive results (and subsequent biopsy). In contrast, women ages 40 to 49 with extremely dense breasts should know that annual screening may decrease the risk of advanced-stage disease, but could also result in a higher likelihood of false-positive results.
Elderly Women Benefit from Screening Mammography
Regular mammograms among women 80 years of age and older may detect earlier stages of breast cancer according to an early online publication in the Journal of Clinical Oncology. Breast cancer rates among women age 70 and older account for approximately 40% of all breast cancers and cancers found in elderly women are often as aggressive as those seen among younger patients.
Currently, the National Cancer Institute recommends that women 50 years and older receive mammograms every one to two years. In the current study, researchers sought to evaluate screening mammography guidelines for women age 80 years and older. The goal of the study was to determine at what stage mammography tended to detect breast cancer in this patient population as well as the survival of women diagnosed with breast cancer in this age group. Researchers examined the records from a U.S. Medicare database to evaluate 12,538 women, age 80 and older, who were diagnosed with breast cancer between 1996 and 2002. Patients were categorized according to the number of mammograms received during the five-year period before being diagnosed with breast cancer. Each patient was assigned to one of the following categories: non–users, 0 mammograms (49%); irregular users, 1-2 mammograms (29%); and regular users, 3 or more mammograms (22%).
- With each mammogram obtained, women became increasingly (0.37 times) less likely to be diagnosed with late-stage breast cancer. For women who were regular users of mammograms, this could represent a 90% reduction in the likeliness of being diagnosed with late-stage breast cancer.
- Survival associated with factors other than breast cancer was also better among frequent mammogram users, indicating that healthier patients may more frequently use mammography.
Delayed Mammography Affects Breast Cancer Mortality in Women Over Age 75
Older women with an extended period of time between their last mammogram and the diagnosis of breast cancer are at an increased risk of dying from the disease, according to the results of a study presented at the American Association for Cancer Research (AACR) Annual Meeting 2013, held in Washington, D.C., April 6-10. The results indicate that there might be a need for continued screening among women over age 75.
The U.S. Preventive Services Task Force (USPSTF) guidelines indicate the lack of evidence for mammography for women 75 years or older based on the premise that disease would be indolent at advanced age; however, some data indicates that over 60% of breast cancers diagnosed between ages 70 to 79 were moderately or poorly differentiated.
To evaluate whether time between mammograms affected breast cancer mortality, researchers analyzed data from 8,663 women in the Women’s Health Initiative observational study or clinical trial who had been diagnosed with breast cancer during a 12.2-year follow-up. The analysis indicated that an interval of five years or more between last mammogram and breast cancer diagnosis was associated with advanced stage disease in 23 percent of women. In comparison, an interval of six months to a year was associated with advanced stage disease in 20 percent of women. The difference was considered statistically significant.(15)
In an adjusted analysis, the researchers found that a longer interval between mammogram and diagnosis was associated with a significantly increased risk of breast cancer death among women age 75 or older at diagnosis. Women over age 75 who had an interval of five or more years between mammogram and diagnosis (or who had never had a mammogram) had three times the risk of dying from breast cancer compared with women who had an interval of six months to a year between mammogram and diagnosis. The same did not hold true for younger women.
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The reasons for this trend are unclear, but the researchers note that the data may indicate a need for continued mammography screening in older women.
Researchers concluded that regular mammography among women age 80 years and older was associated with detection of earlier stages of breast cancer, although improvement in overall survival was not evident. Healthcare providers may wish to discuss the potential benefits of screening mammography with their elderly patients. (3)
Screening Mammography Performs Poorly in Young Women
Screening mammography in women under age 40 results in high rates of callbacks, low rates of cancer detection, and high rates of false-positive results, according to the results of a study published early online in the Journal of the National Cancer Institute.(4)
Although a great deal of attention has focused on the performance of screening mammography among women over the age of 40, there has been little information available about how mammography performs in very young women—those under the age of 40. To address this question, researchers from the University of North Carolina pooled data from six mammography registries in the United States. Their data included 117,738 women who underwent their first mammogram between the ages of 18 and 39. The researchers then followed the women for a year to determine the accuracy of the tests, evaluate the recall rate, and measure the cancer detection rates. The study included women who had screening mammograms as well as those who underwent diagnostic mammograms (due to a symptom such as a lump).
The researchers found that mammography performance improved in the presence of a breast lump – for diagnostic mammograms, the rate of detection was 14.3 cancers per 1,000 women tested, whereas for screening mammograms, the rate of detection was 1.6 cancers per 1,000 women. The researchers found that the screening mammograms had poor accuracy and high rates of recall for further testing.
The authors concluded that “in a theoretical population of 10,000 women aged 35-39 years, 1,266 women who are screened will receive further workup, with 16 cancers detected and 1,250 women receiving a false-positive result.” They found no cancers in women under the age of 25 and a poor performance of screening mammography in women ages 35-39.
It should be noted that the researchers did not have complete family history information or information about BRCA1 or BRCA2 mutation status, and were therefore not able to fully assess mammography performance in the subset of young women at high risk of breast cancer.
Screening Mammography and Risk of Over-Diagnosis
A potential risk of screening for any type of cancer is that screening will detect a cancer that would never otherwise have come to medical attention. This is referred to as “over-diagnosis.” As a result of over-diagnosis, some individuals receive cancer diagnoses and treatments that they might otherwise have avoided.
As an example of over-diagnosis, consider an individual who has cancer, but who will die of another cause before the cancer causes noticeable health problems. Early detection of this cancer would lead to unnecessary cancer treatment. This sort of situation is generally not possible to predict in advance, but understanding how frequently it occurs can help women make more informed decisions.
Among women who start annual screening mammography at the age of 40, more than half will have a false-positive result (the need to return for additional imaging even though no cancer is present) during the first 10 years of screening. Seven percent of cancer-free women will be advised to have a breast biopsy. These results were published in the Annals of Internal Medicine. A mammogram is an X-ray of the breast. (6)
To explore how the frequency of false-positive results varies with different approaches to screening, researchers conducted a study among almost 170,000 women who had a first screening mammogram at age 40 to 59 years, and 4,400 women with breast cancer. The researchers evaluated false-positive recalls (asking a cancer-free woman to return for additional imaging) as well as false-positive biopsy recommendations (recommending that a cancer-free woman have a breast biopsy).
- Among women who started screening at the age of 40, the likelihood of having a false-positive recall during 10 years of screening was 61% for women who were screened every year and 42% for women who were screened every two years. The likelihood of a false-positive biopsy recommendation was 7% for women screened every year and 5% for women screened every two years.
- Estimates were similar when women started screening at the age of 50, but the lifetime risk of a false-positive result was lower because they had a decade less of screening.
- A false-positive recall was less likely for women who had a previous mammogram available for comparison.
- Among women diagnosed with breast cancer, those who had been screened every two years were somewhat more likely than women screened every year to be diagnosed with late-stage cancer. This result was not statistically significant, however, suggesting that it could have occurred by chance alone.
These results suggest that performing screening mammography every two years (rather than every year) will reduce the frequency of false-positive test results, but may also be linked with a small increase in the risk of being diagnosed with later-stage breast cancer. In another study published in the same issue of the Annals of Internal Medicine, researchers compared how well two different types of mammograms—film and digital—detected breast cancer. (7 )The two approaches performed similarly in most women, although digital mammography appeared to be better than film mammography at detecting estrogen receptor-negative breast cancers and breast cancers in women with very dense breasts. Because these cancers are more common in younger women, younger women may wish to choose digital mammography if they are screened.Women are advised to talk with their healthcare provider about the approach to breast cancer screening that’s right for them.
Breast Cancer Risk after False-Positive Screening Results
Women with false-positive test results for breast cancer may want to remain vigilant with screening, as false-positive results could be associated with underlying pathology that may result in breast cancer, according to the results of a study published in the Journal of the National Cancer Institute.(5)
Although screening mammography can reduce the risk of death from breast cancer (due to early detection), disease screening in healthy individuals can also lead to false-positive test results. A false-positive result suggests that cancer may be present even though the person is actually cancer-free. False-positive results can lead to anxiety and unnecessary additional testing.
Women with false-positive mammography results are usually referred back for routine screening; however, it is unknown whether these women have a higher long-term risk for breast cancer compared to women who initially test negative.
In order to determine if women with false-positive mammography results have a higher risk of developing breast cancer than those who test negative, researchers from the University of Copenhagen evaluated data from a population-based mammography program in Copenhagen, Denmark from 1991-2005. They used the data to measure the risk of breast cancer and ductal carcinoma in situ (DCIS) in 58,003 women between the ages of 50-69 who had received false-positive test results.
The results indicated that women who had tested negative for breast cancer had an absolute cancer rate of 339 per 100,000 person-years at risk, whereas women had tested false-positive had an absolute rate of 583 per 100,000 person-years at risk. Six or more years after the test, the relative risk of breast cancer in women with false-positive results was statistically significantly higher than women who tested negative; however, those statistics lowered when new screening technology was introduced in the year 2000.
It’s important for women to discuss screening options with their physician in order to determine their optimal screening protocol for breast cancer. Based on the results of this study, women with false-positive mammography results may benefit from close monitoring and continued regular screening.
MRI Screening May Detect Breast Cancer Earlier Among BRCA Carriers
Inherited mutations in two genes-BRCA1 and BRCA2-have been found to greatly increase the lifetime risk of developing breast and ovarian cancer. Alterations in these genes can be passed down through either the mother’s or the father’s side of the family. Prophylactic mastectomy (removal of the breasts before cancer develops) reduces the risk of breast cancer among women with BRCA1 and BRCA2 mutations, but is not an acceptable option for some women. For women who decline prophylactic mastectomy, effective breast cancer screening programs are important in order to detect cancer at an early stage. Magnetic resonance imaging (MRI) is an approach to screening that detects a higher proportion of breast tumors than mammography, but also costs a great deal more and produces more false-positive test results.
MRI more accurately detects breast cancer than mammography or ultrasound among women who are at a high risk of developing the disease. Researchers from several medical institutions recently conducted a clinical trial to compare the accuracy of MRI, mammography, and ultrasound in the detection of breast cancer among women with BRCA1 or BRCA2 mutations or those with at least a 20% chance of having these mutations. All screening techniques were performed within 90 days of each other. This study included 195 women with an average age of 46 years.
- Overall, 16 biopsies were performed and six cancers were diagnosed.
- MRI detected all six cancers, mammography detected two, and ultrasound detected one.
- MRI resulted in significantly more biopsies among patients who did not have cancer than mammography or ultrasound.
The researchers concluded: “Screening MRI had a higher biopsy rate but helped detect more cancers than either mammography or [ultrasound].” Women with a strong family history of breast cancer and those who are known BRCA1/BRCA2 mutation carriers may wish to speak with their physician regarding their individual risks and benefits of all types of screening measures.
The addition of MRI to mammography screening in women with a BRCA mutation appears to significantly reduce the incidence of advanced breast cancer. Women who carry a BRCA mutation are at a higher risk for developing breast cancer and therefore may benefit from additional approaches to screening. For years, mammography has been the standard in breast cancer screening; however, MRI has been shown to be more sensitive than mammography,
Canadian researchers divided 1,275 women with a BRCA1 or BRCA2 mutation into two groups: one group (445 women) was screened with MRI plus mammography and the second group, a control group (830 women), was screened with mammography alone. The women were followed for several years in order to determine which screening method detected cancer at an earlier stage. After six years there were 41 cases of breast cancer in the MRI group and 76 in the control group. At six years, the cumulative incidence of ductal carcinoma in situ (DCIS) and Stage I breast cancer was 12.7% in the MRI group compared with 9.5% in the control group. Comparatively, the cumulative incidence of Stage II-IV breast cancers at six years was 2.0% in the MRI group and 7.1% in the control group. The researchers noted that there were proportionately fewer advanced breast cancers and more early cancers among women screened with MRI compared with those in the control group. In addition, cancer size was smaller in the MRI group. The researchers concluded that annual screening with MRI plus mammography is associated with a significant reduction in the incidence of advanced cancers among BRCA carriers. (8)
Research also suggests that among women with BRCA1 or BRCA2 mutations, breast cancer screening with MRI in addition to mammography may be cost-effective for those between the ages of 35 and 54 years. In order to evaluate the cost-effectiveness of adding screening with MRI to mammographic screening in women with BRCA1 or BRCA2 mutations, researchers at Stanford University developed a statistical model. The model estimated the health outcomes and costs of different screening scenarios. These scenarios were no screening; annual mammography from age 25 to age 69; and annual mammography from age 25 to age 69 plus annual MRI for specific age groups.Adding annual MRI to mammographic screening for all women between the ages of 25 and 69 would increase breast cancer detection but would also increase false-positive test results. (9)
- Among BRCA1 mutation carriers, MRI plus mammography would detect 85% of breast tumors compared to 35% with mammography alone.
- Among women with a BRCA1 mutation but no breast cancer, 23% would be wrongly classified as positive using MRI plus mammography, compared to only 4% using mammography alone.
- Results among women with BRCA2 mutations were generally similar.
- The addition of MRI to mammography would increase life expectancy from 71.9 years to 73.3 years among women with BRCA1 mutations, and from 78.8 to 79.6 years among women with BRCA2 mutations.
In analyses of different age groups, the cost-effectiveness of adding MRI to mammography was most apparent for women between the ages of roughly 35 to 54 years. Among women in this age group, the addition of MRI was cost-effective for all BRCA1 carriers, and for BRCA2 carriers with mammographically dense breasts.The researchers conclude that breast cancer screening using MRI in addition to mammography can be cost-effective for certain age groups of women with BRCA1 or BRCA2 mutations. The researchers note, “With substantial declines in its cost, breast MRI screening is likely to represent an acceptable value for a broader group of women.”
Breast Density and Screening
The addition of ultrasound for the screening of breast cancer significantly improves detection rates among women who have dense breast tissue. These results were recently reported in the Journal of the American Medical Association.
Dense breast tissue is associated with an increased risk of developing breast cancer. As well, breast cancer can be difficult to detect in dense breasts: the majority of very early breast cancers are not identified by mammography alone among women with dense breast tissue. Therefore, researchers have been evaluating ways in which to provide more effective and accurate screening for breast cancer among women with dense breast tissue.
Researchers from 21 different medical institutions recently conducted a clinical study to evaluate the effectiveness of a one-time ultrasound screening in addition to mammography for the screening of breast cancer among 2,809 women with dense breast tissue. Each patient underwent both mammography and ultrasound. The following findings were observed:
• The addition of ultrasound to mammography significantly increased the ability to detect breast cancer.
• Ultrasound also resulted in a greater number of false-positive readings (a false reading that cancer is present when it is not).
• The main benefit of ultrasound is the detection of small breast cancers that have not yet spread to lymph nodes in women with very dense breast tissue.
The researchers concluded: “The detection benefit of a single screening ultrasound in women at elevated risk of breast cancer is now well validated”. However, researchers caution that further studies are necessary to provide screening guidelines using ultrasound, particularly due to the increase in false-positive readings.(11)
- Threlfall A, Collins S, Woodman C. Impact of NHL breast screening on advanced disease and mortality from breast cancer in the North West of England. British Journal of Cancer. 2003;89:77-80.
- Tabar L, Yen M-F, Vitak B, et al. The Lancet. 2003;361:1405-1410.
- Badgwell, B., Giordano, S., Zhigang, D., et al. Mammography before diagnosis among women age 80 years and older with breast cancer. Journal of Clinical Oncology [early online publication]. doi:10.1200/JCO.2007.12.8058. 2008.
- Yankaskas BC, Haneuse S, Kapp JM, et al. Performance of first mammography examination in women younger than 40 years. Journal of the National Cancer Institute. Published early online: May 3, 2010.
- Euler-Chelpin MV, Risor LM, Thorsted BL, et al. Risk of breast dancer after false-positive test results in screening mammography. Journal of the National Cancer Institute. Published early online April 5, 2012: doi: 10.1093/jnci/djs176
- Hubbard RA, Kerlikowske K, Flowers CI et al. Cumulative probability of false-positive recall or biopsy recommendations after 10 years of screening mammography. A cohort study. Annals of Internal Medicine. 2011;155:481-492.
- Kerlikowske K, Hubbard RA, Miglioretti DL et al. Comparative effectiveness of digital versus film-screen mammography in community practice in the United States. A cohort study. Annals of Internal Medicine. 2011;155:493-502.
- Warner E. A prospective study of breast cancer incidence and stage distribution in women with a BRCA1 or BRCA2 mutation under surveillance with and without magnetic resonance imaging. Presented at the 32ndCTRC-AACR San Antonio Breast Cancer Symposium. December 9-13, 2009. San Antonio, TX. Abstract 26.
- Plevritis SK, Kurian AW, Sigal BM et al. Cost-Effectiveness of Screening BRCA1/2 Mutation Carriers with Breast Magnetic Resonance Imaging. JAMA. 2006;295:2374-2384.
- Lehman C, Isaacs C, Schnall M, et al. Cancer yield of mammography, MR, and US in high-risk women: prospective multi-institution breast cancer screening Study. Radiology. 2007;244:381-388.
- Berg W, Blume J, Cormack J, et al. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. Journal of the American Medical Association. 2008; 299: 21512163.
- Elmore JG, Reisch LM, Barton MB , et al. Efficacy of breast cancer screening in the community according to risk level. Journal of the National Cancer Institute. 2005;97:1035-1043.
- Kerlikowske K, Zhu W, Hubbard RA, et al. Outcomes of Screening Mammography by Frequency, Breast Density, and Postmenopausal Hormone Therapy. JAMA Internal Medicine. Published early online March 18, 2013. doi:10.1001/jamainternmed.2013.307.
- Simon MS, Wassertheil-Smoller S, Thompson CA, et al. Mammography interval and breast cancer mortality in the Women’s Health Initiative. Presented at the AACR Annual Meeting 2013, held in Washington, D.C., April 6-10. Abstract 157.
- Berry DA, Cronin KA, Plevritis SK et al. Effect of Screening and Adjuvant Therapy on Mortality from Breast Cancer. New EnglandJournal of Medicine. 2005;353:1784-92.
- Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. New England Journal of Medicine. 2012; 367: 1998-2005.
- Comparison of recommendations for screening mammography using CISNET models.” Elizabeth Kagan Arleo, R. Edward Hendrick, Mark A. Helvie, and Edward A. Sickles. CANCER; Published Online: August 21, 2017 (DOI: 10.1002/cncr.30842). URL Upon Publication: http://doi.wiley.com/10.1002/cncr.30842
- On Assessing the Effect of Breast Cancer Screening Schemes,” Otis W. Brawley. CANCER; Published Online: August 21, 2017 (DOI: 10.1002/cncr.30840). URL Upon Publication
- O’Donoghue C, Eklund M, Ozanne EM, et al: Aggregate Cost of Mammography Screening in the United States: Comparison of Current Practice and Advocated Guidelines. Annals of Internal Medicine. 2014;160(3):145-153.