ABSTRACT: Breast cancer is the most commonly diagnosed cancer in women in the United States and the second leading cause of cancer death in American women 1. Regular screening mammography starting at age 40 years reduces breast cancer mortality in average-risk women 2. Screening, however, also exposes women to harm through false-positive test results and overdiagnosis of biologically indolent lesions. Differences in balancing benefits and harms have led to differences among major guidelines about what age to start, what age to stop, and how frequently to recommend mammography screening in average-risk women 2 4.

Breast cancer risk assessment is very important for identifying women who may benefit from more intensive breast cancer surveillance; however, there is no standardized approach to office-based breast cancer risk assessment in the United States. This can lead to missed opportunities to identify women at high risk of breast cancer and may result in applying average-risk screening recommendations to high-risk women. Risk assessment and identification of women at high risk allow for referral to health care providers with expertise in cancer genetics counseling and testing for breast cancer-related germline mutations (eg, BRCA), patient counseling about risk-reduction options, and cascade testing to identify family members who also may be at increased risk.

The purpose of this Practice Bulletin is to discuss breast cancer risk assessment, review breast cancer screening guidelines in average-risk women, and outline some of the controversies surrounding breast cancer screening. It will present recommendations for using a framework of shared decision making to assist women in balancing their personal values regarding benefits and harms of screening at various ages and intervals to make personal screening choices from within a range of reasonable options. Recommendations for women at elevated risk and discussion of new technologies, such as tomosynthesis, are beyond the scope of this document and are addressed in other publications of the American College of Obstetricians and Gynecologists (ACOG) 5 6 7.

Background

General Considerations for Screening

The goal of screening for cancer is to detect preclinical disease in healthy, asymptomatic patients to prevent adverse outcomes, improve survival, and avoid the need for more intensive treatments. Screening tests have both benefits (eg, improved health outcomes) and adverse consequences (eg, cost, anxiety, inconvenience, false-positive results, and other test-specific harms such as overdiagnosis and overtreatment).

Breast self-examination, breast self-awareness, clinical breast examination, and mammography all have been used alone or in combination to screen for breast cancer. In general, more intensive screening detects more disease. Screening intensity can be increased by combining multiple screening methods, extending screening over a wider age range, or repeating the screening test more frequently. However, more frequent use of the same screening test typically is associated with diminishing returns (ie, repeating the test twice as often does not make it twice as effective) and an increased rate of screening-related harms. Determining the appropriate combination of screening methods, the age to start screening, the age to stop screening, and how frequently to repeat the screening tests require finding the appropriate balance of benefits and harms. Determining this balance can be difficult because some issues, particularly the importance of harms, are subjective and valued differently from patient to patient. This balance can depend on other factors, particularly the characteristics of the screening tests in different populations and at different ages.

Varying judgments about the appropriate balance of benefits and harms have led to differences among the major guideline group recommendations for breast cancer screening Table 1 3 4 23. The American College of Obstetricians and Gynecologists has reviewed these guidelines, their supporting evidence and rationale, and the recommendations for shared decision making embedded within them. The American College of Obstetricians and Gynecologists’ recommendations for breast cancer screening presented in this document reflect that screening decisions should incorporate patient values regarding relative benefits and harms. The American College of Obstetricians and Gynecologists’ recommendations emphasize shared decision making in choosing between the range of options encompassed within the U.S. Preventive Services Task Force, American Cancer Society (ACS), and National Comprehensive Cancer Network guidelines. The next few sections of this Practice Bulletin present data on overall benefits and harms of mammography screening. Data for other screening modalities and the differences among benefits and harms of mammography at different ages and screening intervals are presented in “Clinical Considerations and Recommendations” later in this document.

Benefits of Mammographic Screening

To update its screening recommendations, the U.S. Preventive Services Task Force and the ACS recently conducted separate systematic reviews of the evidence for breast cancer screening in average-risk women 2 24. Studying the effect of mammography on mortality is methodologically challenging because of the large number of women needed and long follow-up periods involved. Randomized and observational studies provide important information but have different limitations. Both systematic reviews combined randomized and observational studies and agreed that mammography generally decreases breast cancer mortality. The ACS systematic review noted that the magnitude of the mortality reduction varied across study types and duration of follow-up 2. The ACS systematic review reported that screening mammography was associated with a decreased risk of breast cancer mortality in randomized controlled trials (relative risk [RR], 0.80–0.82); in cohort studies (RR, 0.75; 95% CI, 0.69–0.81); and in modeling studies (median RR, 0.85; ranging from 0.77 to 0.93) 2. The U.S. Preventive Services Task Force evidence review 24 reported results by age Table 2 3. This systematic review also found a reduced risk of advanced breast cancer (stage IIB or greater) with screening mammography in women 50 years and older (RR, 0.62; 95% CI, 0.46–0.83) 24. Although the ACS and U.S. Preventive Services Task Force systematic reviews did not present evidence that screening mammography prevents the need for advanced cancer treatment, it is reasonable to assume that if screening reduces the risk of advanced breast cancer, it may reduce the need for advanced cancer treatment.

The ACS systematic review also examined the effect of screening mammography on life expectancy. Although the review concluded that there was high-quality evidence that mammographic screening increases life expectancy by decreasing breast cancer mortality, the authors were not able to estimate the size of the increase 23.

Adverse Consequences of Screening Mammography

Shared Decision Making

Shared decision making is a process in which patients and physicians share information, express treatment preferences, and agree on a treatment plan (see Committee Opinion No. 587, Effective Patient–Physician Communication 33. It combines the expertise of the physician, who provides the details of the clinical information, including the benefits (eg, decreased risk of dying of breast cancer) and harms (eg, callbacks, benign breast biopsies, overdiagnosis), and the values of the patient, who shares her experiences, concerns, and priorities. The clinical information can be provided in ways that are efficient for patients and physicians (eg, online videos or reliable web pages, informational handouts, or face-to-face conversations). Shared decision making is particularly important for decisions regarding breast cancer screening because many choices involve personal preferences related to potential benefits and adverse consequences. For more information, see ACOG’s online Breast Cancer Screening and Treatment Resource Overview.

Clinical Considerations and Recommendations

How should individual breast cancer risk be assessed?

Health care providers periodically should assess breast cancer risk by reviewing the patient’s history. Breast cancer risk assessment is based on a combination of the various factors that can affect risk Box 1 6 10 11 12 13. Initial assessment should elicit information about reproductive risk factors, results of prior biopsies, ionizing radiation exposure, and family history of cancer. Health care providers should identify cases of breast, ovarian, colon, prostate, pancreatic, and other types of germline mutation-associated cancer in first-degree, second-degree, and possibly third-degree relatives as well as the age of diagnosis. Women with a potentially increased risk of breast cancer based on initial history should have further risk assessment. Assessments can be conducted with one of the validated assessment tools available online, such as the Gail, BRCAPRO, Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm, International Breast Cancer Intervention Studies (IBIS, also known as Tyrer–Cuzick), or the Claus model 34.

Risk assessment is important to determine if a woman is at average or increased risk of breast cancer to guide counseling regarding breast cancer surveillance, risk reduction, and genetic testing. Risk assessment should not be used to consider a woman ineligible for screening appropriate for her age. Rather, risk assessment should be used to identify women who may benefit from genetic counseling, enhanced screening such as magnetic resonance imaging screening, more frequent clinical breast examinations, or risk-reduction strategies. Information regarding screening and risk reduction for women at high risk is discussed elsewhere 4 5 35 36.

A number of validated breast cancer risk assessment tools are readily available online and can be completed quickly in an office setting. Some tools are better for certain risk factors and populations than others. The Gail model www.cancer.gov/bcrisktool has been validated and is widely used. It is of limited use in some women, including those younger than 35 years, those with a family history of breast cancer in paternal family members or in second-degree or more distantly related family members, those with family histories of nonbreast cancer (eg, ovarian and prostate) known to be associated with genetic mutations, and high-risk lesions on biopsy other than atypical hyperplasia (eg, lobular carcinoma in situ). Women who cannot be assessed appropriately with the Gail model can be assessed with other validated tools that incorporate these other elements into risk assessment, including the BRCAPRO, Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm, IBIS, or Claus model 34. One study showed that the IBIS model was more accurate for assessing breast cancer risk based on family history than the Claus or Gail model 37. If a patient’s level of risk is unclear after initial assessment, referral for a more in-depth hereditary cancer risk assessment is appropriate. A hereditary cancer risk assessment is conducted by a genetic counselor or other health care provider with expertise in cancer genetics and includes gathering family history information, risk assessment, education, and counseling 38. This assessment may include genetic testing, if desired, after appropriate counseling and informed consent is obtained.

Is screening breast self-examination recommended in women at average risk of breast cancer, and what should women do if they notice a change in one of their breasts?

Breast self-examination is not recommended in average-risk women because there is a risk of harm from false-positive test results and a lack of evidence of benefit. Average-risk women should be counseled about breast self-awareness and encouraged to notify their health care provider if they experience a change. Breast self-awareness is defined as a woman’s awareness of the normal appearance and feel of her breasts. Breast self-examination is the inspection of a woman’s breasts on a regular, repetitive basis for the purpose of detecting breast cancer. Unlike breast self-examination, breast self-awareness does not include a recommendation for women to examine their breasts in a systematic way or on a routine basis. Rather, it means that a woman should be attuned to noticing a change or potential problem with her breasts. Women should be educated about the signs and symptoms of breast cancer and advised to notify their health care provider if they notice a change such as pain, a mass, new onset of nipple discharge, or redness in their breasts.

In its 2009 breast cancer screening guidelines, the U.S. Preventive Services Task Force recommended against teaching breast self-examination (grade D recommendation) based on the lack of evidence regarding benefits and because of potential harms from false-positive findings 39. The U.S. Preventive Services Task Force did not change this recommendation in the 2016 update of its breast cancer screening guidelines 3. The ACS also no longer recommends breast self-examination for women at average risk of breast cancer because of the lack of evidence regarding improved outcomes 23.

Although breast self-examination is no longer recommended, evidence on the frequency of self-detection of breast cancer provides a strong rationale for breast self-awareness in the detection of breast cancer. Approximately 50% of cases of breast cancer in women 50 years and older and 71% of cases of breast cancer in women younger than 50 years are detected by women themselves 40 41. For example, 43% of the 361 breast cancer survivors who participated in the 2003 National Health Interview Survey reported detecting their cancer themselves 42. Additional evidence of the important role of breast cancer self-detection comes from a study of low-income women who received breast cancer care through California’s Breast and Cervical Cancer Treatment Program. Of the 921 women in the cohort, 64% self-detected their breast cancer 43.

Although there are no studies in the United States that have directly examined the effectiveness of breast self-awareness, based on the frequent incidence of self-detected breast cancer, patients should be counseled about breast self-awareness. The U.S. Preventive Services Task Force “supports all patients being aware of changes in their bodies and discussing these changes with clinicians” 3. The ACS states clinicians should counsel women “regarding the importance of being alert to breast changes” 23.

Should practitioners perform routine screening clinical breast examinations in average-risk women?

Screening clinical breast examination may be offered to asymptomatic, average-risk women in the context of an informed, shared decision-making approach that recognizes the uncertainty of additional benefits and the possibility of adverse consequences of clinical breast examination beyond screening mammography. If performed for screening, intervals of every 1–3 years for women aged 25–39 years and annually for women 40 years and older are reasonable. The clinical breast examination continues to be a recommended part of evaluation of high-risk women and women with symptoms.

There are conflicting guidelines from the National Comprehensive Cancer Network, ACS, and the U.S. Preventive Services Task Force on whether to perform screening clinical breast examination in women at average risk of breast cancer Table 1 3 4 23. The recent ACS systematic review found no studies directly estimating the association between clinical breast examination and mortality 2. However, three studies in the systematic review looked at false-positive test results in combination with mammography, and two noted there are approximately 55 false-positive test results for every one case of cancer detected. A supplemental systematic review on clinical breast examination performance characteristics conducted for the ACS recommendation report estimated that clinical breast examination will detect approximately 2–6% more cases of invasive cancer than mammography alone; however, there was no evidence that patient outcomes were improved by detection of these additional cases of cancer 23. Given the lack of evidence for benefit combined with the increase in false-positive test results, the ACS no longer recommends clinical breast examination. In its 2009 breast cancer screening guidelines, the U.S. Preventive Services Task Force similarly stated that there was insufficient evidence to assess the benefits and harms of the clinical breast examination (category I recommendation) 39; and, it did not change this recommendation in the 2016 update of the guidelines 3. The National Comprehensive Cancer Network continues to recommend clinical breast examination at intervals of 1–3 years for asymptomatic, average-risk women aged 25–39 years and annually for asymptomatic, average-risk women aged 40 years and older.

When should screening mammography begin in average-risk women?

Women at average risk of breast cancer should be offered screening mammography starting at age 40 years. Women at average risk of breast cancer should initiate screening mammography no earlier than age 40 years. If they have not initiated screening in their 40s, they should begin screening mammography by no later than age 50 years. The decision about the age to begin mammography screening should be made through a shared decision-making process. This discussion should include information about the potential benefits and harms. The use of information sheets or decision aids can assist health care providers and patients with this discussion. For more information, see ACOG’s online Breast Cancer Screening and Treatment Resource Overview.

The decision about when to recommend initiating screening is driven by a number of factors that vary with age, including risk of breast cancer, risk of death from breast cancer, likelihood of screening mammography to diagnose cancer, risk of false-positive test results and other harms, and the balance between benefits and harms. One measure of the efficiency of breast cancer screening is the number needed to screen, which is a measure of overall risk reduction useful for comparing effectiveness of screening between populations. The number needed to screen depends largely on the mortality benefit from screening and the incidence of the disease in the population screened. The U.S. Preventive Services Task Force and the ACS reviewed these issues at length in preparation for their guideline revisions 2 24, 25.

The distribution of breast cancer cases and deaths by age at diagnosis increase with age starting in the 40s and continue through the 50s. The incidence of breast cancer also increases as women age 23. Mammography appears to provide better mortality reduction as women get older Table 2 2 3 24. Harms appear to decrease, with approximately the same number of biopsies performed across age groups, and a higher proportion leading to cancer diagnoses in older women 3. Because breast cancer is less common in women younger than 40 years, the frequency of harms associated with screening mammography is higher relative to the benefits (lives saved) in this age group. Thus, the risk–benefit balance improves with age. In its systematic review, the ACS extracted relative risks and calculated the number needed to screen by age group; the results showed effectiveness of screening for all age groups, but efficiency of screening improved with age and assumed mortality reduction with screening 2.

The recommended age of initiation of mammography in average-risk women differs among the consensus guidelines groups in the United States Table 1 3 4 23. The ACS and the U.S. Preventive Services Task Force recognize that although mammography starting at age 40 years is less effective and more frequently associated with harms than in older women, it does save lives. Benefits and adverse consequences vary over a continuum, and selection of a specific age for initiation of screening is largely a subjective decision that balances benefits and harms according to an individual woman’s values and preferences.

The U.S. Preventive Services Task Force chose their starting age of 50 years based on an analysis of benefits (measured by fewer breast cancer deaths and more life years gained) and various measures of harm across the lifetimes of women screened biennially starting at age 40 years compared with those screened biennially starting at age 50 years Table 3 3. The Task Force noted that for women in their 40s, mammography results in only a small decrease in breast cancer deaths compared with a proportionately larger increase in callbacks and benign biopsies. Of note, the estimated years of life gained was substantially greater in women beginning screening at a younger age, which would be expected because this age group has the largest potential years of life lost from cancer. The Task Force summarized as follows 3:

The ACS made a qualified recommendation that women should have the opportunity to begin screening at age 40 years and a strong recommendation that women should undergo regular screening mammography starting at age 45 years based on an analysis of burden of disease by 5-year intervals 23. The analysis noted that the 5-year risk in women aged 45–49 years (0.9%) was similar to women aged 50–54 years (1.1%) as was the proportion of incident breast cancer cases (10% and 12%, respectively). However, the 5-year risk and the proportion of incident breast cancer cases were lower in 40–44-year-olds (5-year risk, 0.6%; proportion of incident breast cancer cases, 7%). The ACS provides a qualified recommendation that women between the ages of 40 years and 44 years should have the opportunity of initiating screening 23.

The National Comprehensive Cancer Network recommends annual screening mammograms starting at age 40 years for all average-risk women 4. The American College of Obstetricians and Gynecologists�� recommendation to offer mammography to average-risk women beginning at age 40 years and to initiate screening by no later than age 50 years is consistent with all three major consensus guidelines Table 1 3 4 23. Given the reduction in mortality and years of life extended by screening women starting at age 40 years, it is appropriate to begin offering screening starting at age 40 years using shared decision making involving a discussion of the anticipated benefits and adverse consequences. Given that the benefit-to-harm ratio improves with age, women who have not chosen to initiate mammography in their 40s should begin screening by no later than age 50 years.

How frequently should screening mammography be performed in average-risk women?

Women at average risk of breast cancer should have screening mammography every 1 or 2 years based on an informed, shared decision-making process that includes a discussion of the benefits and harms of annual and biennial screening and incorporates patient values and preferences. Biennial screening mammography, particularly after age 55 years, is a reasonable option to reduce the frequency of harms, as long as patient counseling includes a discussion that with decreased screening comes some reduction in benefits.

Neither the ACS nor the U.S. Preventive Services Task Force systematic review identified any randomized trials directly comparing annual to biennial screening. However, both groups reviewed indirect evidence from meta-analyses and observational studies. Table 4 contains a summary of data from the ACS review, which was supplemented with additional work commissioned for the final recommendations document 2, 23, 26, 32, 44, 45. These data suggest that shorter screening intervals are associated with improved outcomes (most clearly for women younger than 50 years) and an increase in callbacks and biopsies. However, the nature of the retrospective data makes it difficult to estimate the extent of benefits and the trade-off with harms. The the U.S. Preventive Services Task Force and the ACS used modeling studies from the Cancer Intervention and Surveillance Modeling Network to make their recommendations. The U.S. Preventive Services Task Force commissioned updated modeling studies from the Cancer Intervention and Surveillance Modeling Network that were not available at the time of the ACS review Table 5 3 31. The updated model predicted that annual screening will result in two additional lives saved balanced against 82 additional biopsies and six overdiagnosed breast tumors for every 1,000 women screened between the ages of 50 years and 74 years 3 31.

Annual screening intervals appear to result in the least number of breast cancer deaths, particularly in younger women, but at the cost of additional callbacks and biopsies. In light of this, the National Comprehensive Cancer Network continues to recommend annual screening 4. The ACS recommends that women should be offered the opportunity to begin annual screening at age 40 years and that women aged 55 years and older should transition to biennial screening or have the opportunity to continue screening annually. The rationale for managing the age groups differently is that “screening annually appears to provide additional benefit over biennial screening particularly in younger women” 23. The U.S. Preventive Services Task Force continues to recommend biennial screening at all ages based on the rationale that the mortality benefit is extended to approximately 80% of the population with biennial screening and that there are considerably fewer harms (eg, callbacks and benign breast biopsies) 3.

Clinicians should initiate a discussion about the frequency of screening once a woman has decided to initiate screening. Clinicians and patients should engage in shared decision making that includes a discussion of the trade-offs between benefits and harms and supports the woman’s decision to choose the screening frequency that achieves the trade-off consistent with her values and concerns. A woman who chooses annual screening may place greater value on the potential for averting breast cancer death and less value on the possible harms. A woman who chooses biennial screening may be more concerned about experiencing the potential harms of screening than she is about the incremental chance of a breast cancer death that could have been averted. Given that the benefit of more frequent screening decreases in older women, a hybrid approach to screening in which a woman initially chooses annual screening and then decreases to biennial after age 55 years also is a reasonable option.

When should screening mammography cease?

Women at average risk of breast cancer should continue screening mammography until at least age 75 years. Age alone should not be the basis to continue or discontinue screening. Beyond age 75 years, the decision to discontinue screening mammography should be based on a shared decision-making process informed by the woman’s health status and longevity.

More than one quarter of cases of breast cancer are diagnosed in women 75 years and older 23, but there are limited data on screening mammography in this population. The systematic reviews conducted for the ACS and the U.S. Preventive Services Task Force did not identify any randomized clinical trials of screening mammography conducted in women 75 years and older. Furthermore, neither review specifically cited any observational data from studies of women older than 74 years. Even for women aged 70–74 years, both reviews presented only limited data on screening mammography 2 24. The ACS guidelines paper 23 cites the results of two observational trials 46 47 that showed a reduction in breast cancer mortality associated with mammographic detection of breast cancer in women 75 years and older. To address the lack of clinical evidence on screening mammography in older women, both the ACS and the U.S. Preventive Services Task Force used data from modeling studies to help inform their guidelines. The most recent simulation study, which did not include women older than 74 years, suggested that women aged 70–74 years can have a reduction in mortality with screening mammography if they remain in good health, but not if they have significant comorbidities 48. The prior Cancer Intervention and Surveillance Modeling Network modeling study included women up to age 84 years, and showed benefit 49.

The U.S. Preventive Services Task Force concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women 75 years and older 3. The ACS provided a qualified recommendation that women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer 23. This recommendation is based on the rationale that as women get older, competing causes of death lower the benefit of screening mammography, particularly if women have substantial comorbidities 23 50.

Determining candidates for screening mammography among women older than 75 years requires assessing their general health and estimating their life expectancy. Many women 75 years and older are in good health and can be expected to live considerably longer than 10 years, and more than one half of women older than 80 years are expected to live more than 10 years 51. Women with a life expectancy of less than 10 years are unlikely to have an appreciable mortality reduction from mammographic detection of an early breast cancer and are at a substantial risk of discomfort, anxiety, and decreased quality of life from adverse effects of treatment that is unlikely to extend their life. Despite the general consensus that women with less than 10 years of life expectancy should not routinely receive screening mammography 3 4 23 52, women who are unlikely to benefit because of serious comorbidities still get screening mammograms 53 54. Even in women younger than 75 years, health assessment is important to determine appropriateness of screening mammography because women of any age with serious comorbidities are unlikely to benefit from screening. In addition, screening mammography should not be performed on women who would not choose further evaluation or treatment based on abnormal screening results. Clinical judgment and predictive models that combine age, comorbidities, and functional status can be used to identify women who may continue to benefit from screening mammography (generally defined as having greater than a 50% probability of surviving 10 years) 55.There also are simplified online tools that use pictograms and list possible benefits and harms that may help with decision making for older women contemplating screening mammography. For more information, see ACOG’s online Breast Cancer Screening and Treatment Resource Overview. Consultation with the patient’s other health care providers also may be helpful.

Summary of Recommendations

Recommendations based on good and consistent scientific evidence (Level A)

• Women at average risk of breast cancer should be offered screening mammography starting at age 40 years. Women at average risk of breast cancer should initiate screening mammography no earlier than age 40 years. If they have not initiated screening in their 40s, they should begin screening mammography by no later than age 50 years. The decision about the age to begin mammography screening should be made through a shared decision-making process. This discussion should include information about the potential benefits and harms.

• Women at average risk of breast cancer should have screening mammography every 1 or 2 years based on an informed, shared decision-making process that includes a discussion of the benefits and harms of annual and biennial screening and incorporates patient values and preferences. Biennial screening mammography, particularly after age 55 years, is a reasonable option to reduce the frequency of harms, as long as patient counseling includes a discussion that with decreased screening comes some reduction in benefits.

• Women at average risk of breast cancer should continue screening mammography until at least age 75 years.

Recommendations based on limited or inconsistent scientific evidence (Level B)

• Health care providers periodically should assess breast cancer risk by reviewing the patient’s history.

• Women with a potentially increased risk of breast cancer based on initial history should have further risk assessment.

• Breast self-examination is not recommended in average-risk women because there is a risk of harm from false-positive test results and a lack of evidence of benefit.

Recommendations based primarily on consensus and expert opinion (Level C)

• Screening clinical breast examination may be offered to asymptomatic, average-risk women in the context of an informed, shared decision-making approach that recognizes the uncertainty of additional benefits and the possibility of adverse consequences of clinical breast examination beyond screening mammography. If performed for screening, intervals of every 1–3 years for women aged 25–39 years and annually for women aged 40 years and older are reasonable. The clinical breast examination continues to be a recommended part of evaluation of high-risk women and women with symptoms.

• Average-risk women should be counseled about breast self-awareness and encouraged to notify their health care provider if they experience a change. Breast self-awareness is defined as a woman’s awareness of the normal appearance and feel of her breasts.

• Age alone should not be the basis to continue or discontinue screening. Beyond age 75 years, the decision to discontinue screening mammography should be based on a shared decision making process informed by the woman’s health status and longevity.

For More Information

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at http://www.acog.org/Womens-Health/Breast-Cancer-Screening.

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s website, or the content of the resource. These resources may change without notice.