Breast Cancer Screening

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For Who?		By Whom?^b	How Often?
Empowerment
Women of all ages	Educate on: Breast awareness (Table 1.) Risk factors of breast cancer Primary preventive measures for breast cancer (Table 2.) Importance of breast cancer screening	Primary Healthcare Providers	Opportunistically
	Advise against Clinical breast examination and Self-breast examination for breast cancer screening
Assessment
Women of all ages	Assess: (1) Risk for breast cancer BRCA1/2 deleterious mutation Personal history of breast diseases or radiation therapy to chest for treatment between 10 to 30 years Family history of breast/ovarian cancer Number of 1^o vs. 2^o degree relative and Age at diagnosis Genetic mutation Other risk factors by breast cancer risk assessment tool for local women (www.cancer.gov.hk/bctool) History of benign breast disease Early age of menarche Nulliparity Late age of first live birth High body mass index Physical inactivity (2) Presence of symptoms and signs suggestive of breast cancer² Presence of breast or axillary lump Change in size or shape of breasts Change in skin texture of breasts or nipple Nipple rash, discharge or retraction New and persistent discomfort or pain in the breast or axilla	Nurses Doctors	Opportunistically
Women with symptoms or signs suggestive of breast cancer	Refer to seek early medical attention^#	^#Nurses	When symptomatic or having signs
	OR
	Provide work up assessment^	^Doctors
Screening
Asymptomatic women who are eligible for breast cancer screening	Discuss screening methods, and address misconceptions and concerns	Nurses Doctors	Opportunistically
Women aged 35 or above who had radiation therapy to chest for treatment between age 10 to 30²	Offer screening by Mammography + Consider additional MRI	Doctors	Annually
Confirmed carriers of BRCA1/2 deleterious mutations²	Starting at age 35 or 10 years prior to the age at diagnosis of the youngest affected relative (whichever is earlier), but not < age 30:
	Offer screening by Mammography	Doctors	Annually
	+ Consider additional MRI
	Offer referral to specialist cancer clinic if wishing to consider prophylactic surgery / chemoprevention for advice and counselling
Women who have any first degree female relative with confirmed BRCA1/2 deleterious mutations	Starting at age 35 or 10 years prior to the age at diagnosis of the youngest affected relative (whichever is earlier), but not < age 30:
	Offer screening by Mammography	Doctors	Annually
	Offer referral to specialist cancer clinic for genetic counselling and testing*
Women at high risk due to other types of family history	Starting at age 35 or 10 years prior to the age at diagnosis of the youngest affected relative (whichever is earlier), but not < age 30:
	Offer screening by Mammography	Doctors	Annually
	Discuss and consider to offer referral to specialist cancer clinic for genetic counselling and testing*
Other women aged 35 or above with high risk*	Offer screening by Mammography	Doctors	Annually
Women at moderate risk^#	Offer screening by Mammography	Doctors	Biennially
Asymptomatic women aged 44 to 69 who are at increased risk^& according to assessment tool	Offer screening by Mammography	Doctors	Biennially
Management
Women who underwent mammography screening⁴	Manage result according to the BI-RADS guideline (Table 3.)	Doctors	When result available

1. Empowerment

a. For Who: Women of all ages

Recommended Care Components^a:

Educate on:

Breast awareness (Table 1.)
Risk factors of breast cancer
Primary preventive measures for breast cancer (Table 2.)
Importance of breast cancer screening

                                            Advise against Clinical breast examination and Self-breast examination for breast cancer screening
                                        

By Whom^b: Primary Healthcare Providers

How Often: Opportunistically

2. Assessment

a. For Who: Women of all ages

Recommended Care Components^a:

Assess:
(1) Risk for breast cancer

BRCA1/2 deleterious mutation
Personal history of breast diseases or radiation therapy to chest for treatment between 10 to 30 years
Family history of breast/ovarian cancer
- Number of 1^o vs. 2^o degree relative and Age at diagnosis
- Genetic mutation
Other risk factors by breast cancer risk assessment tool for local women (www.cancer.gov.hk/bctool)
- History of benign breast disease
- Early age of menarche
- Nulliparity
- Late age of first live birth
- High body mass index
- Physical inactivity

(2) Presence of symptoms and signs suggestive of breast cancer²

Presence of breast or axillary lump
Change in size or shape of breasts
Change in skin texture of breasts or nipple
Nipple rash, discharge or retraction
New and persistent discomfort or pain in the breast or axilla

By Whom^b: Nurses / Doctors

How Often: Opportunistically

b. For Who: Women with symptoms or signs suggestive of breast cancer

Recommended Care Components^a:

                                            Refer to seek early medical attention#

                                            OR

                                            Provide work up assessment^

By Whom^b: ^#Nurses / ^Doctors

How Often: When symptomatic or having signs

3. Screening

a. For Who: Asymptomatic women who are eligible for breast cancer screening

Recommended Care Components^a:

Discuss screening methods, and address misconceptions and concerns

By Whom^b: Nurses / Doctors

How Often: Opportunistically

b. For Who: Women aged 35 or above who had radiation therapy to chest for treatment between age 10 to 30²

Recommended Care Components^a:

                                            Offer screening by Mammography

                                            + Consider additional MRI

By Whom^b: Doctors

How Often: Annually

c. For Who: Confirmed carriers of BRCA1/2 deleterious mutations²

Recommended Care Components^a:

                                            Starting at age 35 or 10 years prior to the age at diagnosis of the youngest affected relative (whichever is earlier), but not < age 30:

                                            Offer screening by Mammography

                                            + Consider additional MRI

                                            Offer referral to specialist cancer clinic if wishing to consider prophylactic surgery / chemoprevention for advice and counselling

By Whom^b: Doctors

How Often: Annually

d. For Who: Women who have any first degree female relative with confirmed BRCA1/2 deleterious mutations

Recommended Care Components^a:

                                            Starting at age 35 or 10 years prior to the age at diagnosis of the youngest affected relative (whichever is earlier), but not < age 30:

                                            Offer screening by Mammography

                                            Offer referral to specialist cancer clinic for genetic counselling and testing*

By Whom^b: Doctors

How Often: Annually

e. For Who: Women at high risk due to other types of family history

Recommended Care Components^a:

                                            Starting at age 35 or 10 years prior to the age at diagnosis of the youngest affected relative (whichever is earlier), but not < age 30:

                                            Offer screening by Mammography

                                            Discuss and consider to offer referral to specialist cancer clinic for genetic counselling and testing*

By Whom^b: Doctors

How Often: Annually

f. For Who: Other women aged 35 or above with high risk*

Recommended Care Components^a:

Offer screening by Mammography

By Whom^b: Doctors

How Often: Annually

g. For Who: Women at moderate risk^#

Recommended Care Components^a:

Offer screening by Mammography

By Whom^b: Doctors

How Often: Biennially

h. For Who: Asymptomatic women aged 44 to 69 who are at increased risk^& according to assessment tool

Recommended Care Components^a:

Offer screening by Mammography

By Whom^b: Doctors

How Often: Biennially

4. Management

a. For Who: Women who underwent mammography screening⁴

Recommended Care Components^a:

Manage result according to the BI-RADS guideline (Table 3.)

By Whom^b: Doctors

How Often: When result available

MRI = Magnetic Resonance Imaging; BI-RADS = Breast Imaging-Reporting and Data System

^a	Grade of recommendation according to colour code: Recommended (Strong) Conditionally recommended Practice points Generally not recommended Not recommended (Strong)

Primary Healthcare Providers – All providers of health services in primary healthcare settings
Primary Healthcare Professionals – Includes doctors, dentists, chinese medicine practitioners, nurses, pharmacists, physiotherapist, occupational therapist, dietitians
“Trained” Healthcare Professionals – Additional post-qualification training required to deliver the respective care component(s)

Figure 1. Breast Cancer Screening Workflow

Table 1. The Breast Awareness 4-point Code⁵

To empower women on their own breast health and facilitate early detection of abnormalities, all women are advised to be “Breast Aware”, i.e. to familiarize themselves with the normal look and feel of their breasts, and to consult a doctor promptly if they notice any unusual changes.^{2, 6}

Breast Awareness 4-Point Code
	Educate on what is normal	During childbearing years, breasts frequently become larger, tender, and lumpy just before menstruation, but they typically return to their normal state afterwards. After menopause, breast tissue is often less dense and firm, and becomes fattier, making breasts feel softer.
	Educate on breast changes to look and feel for	The breast Change in the outline, shape or size Puckering or dimpling of the skin Any new discrete lump Unusual pain or discomfort, particularly if new, persistent and localized The nipple Recent inversion or change in shape Any discharge Rash around the nipple The armpit Swelling under the armpit Constant pain
	Encourage to look and feel their breasts	Encourage women to examine their breasts by looking in a mirror while changing or to feel them during bathing or while lying down.
	Encourage to seek medical attention if breast abnormalities are noticed	If any breast changes are noticed, advise them to seek medical consultation promptly.

Source: https://www.fhs.gov.hk/english/health_info/woman/12545.html

Table 2. CEWG Recommendation on Primary Preventive Measures for Breast Cancer²

Primary Prevention of Breast Cancer
	Certain breast cancer risk factors are modifiable and related to personal lifestyle and behaviour. Women can lower their risk of getting breast cancer by pursuing primary preventive measures below: *Be physically active:* Women should do at least 150 minutes of moderate-intensity or equivalent aerobic physical activities per week (e.g. climbing stairs or brisk walking) *Do not drink alcohol* *Maintain healthy body weight:* Asian women should aim for a body mass index (BMI) between 18.5 and 22.9, and a waist circumference of less than 80 cm (~32 inch) *Have childbirth at an earlier age and breastfeed each child for a longer duration**

Primary Prevention of Breast Cancer

Certain breast cancer risk factors are modifiable and related to personal lifestyle and behaviour. Women can lower their risk of getting breast cancer by pursuing primary preventive measures below:

Be physically active: Women should do at least 150 minutes of moderate-intensity or equivalent aerobic physical activities per week (e.g. climbing stairs or brisk walking)
Do not drink alcohol
Maintain healthy body weight: Asian women should aim for a body mass index (BMI) between 18.5 and 22.9, and a waist circumference of less than 80 cm (~32 inch)
Have childbirth at an earlier age and breastfeed each child for a longer duration*

CEWG = Cancer Expert Working Group; BMI = Body Mass Index
*Breast feeding for at least 5-6 months has a protective effect on the risk of developing breast cancer⁷

Table 3. Management of Mammography Results

Further Readings Community Resources Reference Materials for Healthcare Professionals Education and Self-Help Materials for the General Public References