Breast Cancer Screening and Diagnosis Clinical Practice Guidelines (2018)

National Comprehensive Cancer Network

Reviewed and summarized by Medscape editors

December 05, 2018

The guidelines on breast cancer screening and diagnosis were released in November 2018 by the NCCN.[1]

Imaging after Screening Mammography Recall

Recommendations for follow-up screening mammography are based on Breast Imaging – Reporting and Data System (BI-RADS) categories, as follows:

Category 1 (negative finding) or category 2 (benign) - Resume routine screening.

Category 3 (probably benign) - Diagnostic mammograms at 6 months, then every 6 to 12 months for 1 to 2 years as appropriate.

Categories 4 and 5 (suspicious or highly suggestive of malignancy) - Tissue diagnosis using core needle biopsy (preferred) or needle localization excisional biopsy with specimen radiograph; benign results with pathology/image concordance should be followed up with mammography every 6 to 12 months for 1 to 2 years before returning to routine screening.

Category 6 (proven malignancy) – Manage as breast cancer.

Diagnostic Evaluation for Patients with Symptoms or Positive Physical Examination Findings

Palpable mass in women aged 30 years or older

The initial evaluation begins with a diagnostic mammogram and ultrasound; in some clinical circumstances, such as a mass with low clinical suspicion or suspected simple cyst, ultrasound would be preferred and may suffice for women 30-39 years of age.

Solid mass

If probably benign (BI-RADS category 3), observation is an option if clinical suspicion for breast cancer is low, with physical examination follow-up with or without ultrasound or diagnostic mammogram every 6 months for 1 to 2 years; tissue (core needle) biopsy is an option if the mass is clinically suspicious. For solid masses with a BI-RADS 4 to 5, a tissue (core needle) biopsy is recommended.

Simple cyst

Patients can be followed with routine screening.

Complicated cyst

Aspiration, or short-term follow-up with physical examination and ultrasonography with or without mammography every 6 to 12 months for 1 to 2 years to assess stability.

Complex (cystic and solid) mass

Perform tissue (core needle) biopsy.

No imaging abnormality

Perform tissue biopsy (core needle biopsy) in patients with suspicious clinical findings; in those with low clinical suspicion, consider observation with or without mammogram and ultrasound for 1 to 2 years to assess stability.

Palpable mass in women younger than 30 years

Proceed directly to ultrasound; mammogram may be considered if ultrasound or clinical breast examination results are highly suspicious or suggestive of cancer or if the patient is at high risk for breast cancer based on personal and family history.

Observation of the mass for 1 or 2 menstrual cycles is an option in cases with low clinical suspicion; if the mass resolves or is stable, the patient may return to routine care. If there is significant increase in size or increase in clinical suspicion, ultrasound should be performed. Needle sampling before imaging is not recommended.

If no ultrasonographic abnormality is found, a mammogram is recommended in cases where there is clinical suspicion. Management on the basis of mammogram results is identical to that for older women. If the clinical suspicion is low, physical examination every 3 to 6 months for 1 to 2 years is recommended with or without ultrasound. If the mass increases in size during the observation period, diagnostic mammogram may be considered followed by tissue (core needle) biopsy. If the mass remains stable, routine breast care is recommended.

Nipple discharge without a palpable mass

Nonspontaneous, multiple-duct discharge - In women <40 years, observation plus education of the patient to stop compression of the breast and to report the development of any spontaneous discharge; in women ≥40 years, mammography and a further workup based on the BI-RADS category.

No palpable mass but persistent, spontaneous, unilateral, single-duct, and clear or bloody discharge - Image with age-appropriate diagnostic mammography and ultrasound

When overall imaging BI-RADS assessment is category 1–3, either a ductogram or MRI are optional to guide the duct excision; management options include duct excision or follow-up with physical exam after 6 months and imaging with diagnostic mammogram with or without ultrasound for 1 to 2 years, with tissue biopsy if clinical suspicion increases during follow-up.

For BI-RADS category 4 or 5 - Tissue biopsy. If the biopsy findings are benign, a ductogram is optional, but surgical duct excision would still be necessary. If findings are indicative of malignancy, treat as for breast cancer.

Asymmetric thickening or nodularity

In women < 30 years with no high risk factors, ultrasound evaluation is appropriate followed by consideration of diagnostic mammography

In woman ≥30 years, obtain a diagnostic mammogram and an ultrasound evaluation

In patients with overall imaging findings in BI-RADS category 1–3 and benign clinical assessment, perform clinical re-examination with imaging as needed in 3 to 6 months to assess stability; age-appropriate diagnostic mammogram and/or ultrasound may be performed every 6 to 12 months for 1 to 2 years to assess stability. If the findings on physical exam and/or imaging are stable, routine screening can be resumed. If either or both findings indicate progression, investigate as for palpable mass.

If a clinically suspicious change is noted or the overall imaging findings are classified as BI-RADS assessment category 4 or 5, a tissue biopsy is recommended.

Breast skin changes

Perform bilateral diagnostic mammogram with or without ultrasound imaging.

In patients with overall BI-RADS assessment category 1–3, perform punch biopsy of the skin or nipple biopsy.

With overall BI-RADS assessment category 4 or 5, perform a tissue biopsy (preferably a core needle biopsy, with or without punch biopsy, although surgical excision is also an option).

Axillary mass

Localized axillary mass (unilateral or bilateral) and no signs of lymphoma - If complete clinical evaluation finds no other sites of adenopathy or non-breast etiologies of adenopathy, perform ultrasound with mammogram for those ≥30 years and ultrasound for those <30 years; a palpable axillary mass with negative/benign imaging results should be clinically managed as appropriate, depending on level of clinical suspicion. A core needle biopsy is recommended for palpable axillary mass that is suspicious or highly suggestive on imaging.

Breast pain

Cyclic or diffuse and nonfocal breast pain with normal physical findings, and screening mammograms are current and negative – Reassure the patient and treat the pain with symptomatic management.

Focal breast pain - Diagnostic mammogram with or without ultrasound for patients ≥30 years; ultrasound for those <30 years.

For more information, see Breast Cancer Screening.

For more Clinical Practice Guidelines, please go to Guidelines.


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