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ACP develops three different types of clinical recommendations:

Clinical Practice Guidelines, Clinical Guidance Statements, and Best Practice Advice. ACP's goal is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible.

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Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.

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A 29-year-old woman is evaluated during a routine examination. She performs monthly breast self-examinations and has not noticed any nipple discharge, skin changes, or masses. She is nulliparous. Her medical history is significant for Hodgkin lymphoma, which was diagnosed 10 years ago and required chemotherapy and mantle radiation. There is no family history of breast or ovarian cancer. She takes levothyroxine for hypothyroidism.

On physical examination, there is no lymphadenopathy. Breast examination discloses no lumps, redness, or edema. The remainder of the physical examination is normal.


Which of the following is the most appropriate recommendation regarding breast cancer screening at this time?

The most appropriate recommendation is bilateral mammography and breast MRI yearly. Patients at high risk for breast cancer should undergo screening earlier than the general population. This patient has a history of mantle radiation, which increases her lifetime risk of breast cancer to more than 25%. She is nulliparous, which also increases her risk for breast cancer. Although no data currently exist supporting early-onset radiographic screening in high-risk subgroups, an expert panel convened by the American Cancer Society recommended that patients who received mantle radiation, as well as those who are carriers of the BRCA1 or BRCA2 mutation, should undergo yearly mammography and breast MRI. MRI is more sensitive than mammography in detecting breast cancer but results in more false-positive test results. Despite the increased MRI test sensitivity, there are as of yet no data supporting decreased mortality from breast cancer using this screening modality.

Breast ultrasonography is not sensitive enough to detect breast cancer, especially in high-risk groups.

A number of blood tests have been suggested as potential early signals for recurrent breast cancer, including CA 15-3, carcinoembryonic antigen (CEA), and CA 27.29. However, none of these tests are recommended for routine surveillance because their use has not resulted in increased survival among patients with breast cancer. Similarly, blood tests such as CA-27.29 have not been shown to be useful for breast cancer detection.

Performing no screening is not appropriate because this patient is at increased risk for breast cancer owing to her history of mantle radiation therapy.

Key Point

  • Screening for breast cancer in high-risk populations consists of yearly breast MRI and bilateral mammography.
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