Recommendations from the European Breast Cancer Guidelines

These recommendations aim to determine the best screening frequency for women in the age ranges for which attending organised breast cancer screening programmes is suggested or recommended. Debate about the recommended interval for screening with mammography remains due to the theoretical advantage of earlier diagnosis but a potential increase in harms with shorter screening intervals.

For cancer screening programmes to bring about reductions in breast cancer mortality, a substantial proportion of the population must participate. Programmes with low uptake can be ineffective and can promote inequalities in health-services. For these reasons, the participation rate is a key parameter to assess both the impact of the screening programme and its acceptability among the target population. These recommendations aim to determine the best strategies to invite women to organised breast cancer screening programmes.

Decision aids are defined by the International Patient Decision Aids Standards (IPDAS) Collaboration as evidence-based tools designed to help patients participate in making specific and deliberated choices among different healthcare options. Although several decisions aids have been designed for breast cancer screening only a few of them have been assessed and the levels of informed choice in this setting have remained low. This recommendation aims to determine if a decision aid is better than a regular invitation letter to explain the benefits and harms of mammography screening to women eligible for breast cancer screening.

In the assessment of women who have a screening mammography showing suspicious findings, the aim is to minimise the need for surgical removal of non-clinically relevant lesions and, at the same time, to minimise the risk of missing a clinically relevant lesion. The only way to significantly reduce both risks is to perform pre-surgical cytology or histopathology assessment of suspicious lesions. Currently, there are two non-operative methods to obtain samples of a breast lesion: fine needle aspiration cytology involves the removal of cells which does not conserve the architectural structure of the lesion and needle core biopsy which removes tissue from the lesion. This recommendation evaluates these two different methods.

A woman who has a an abnormal mammogram or other screening test, and is told that she has calcium deposits in her breast, called calcifications or microcalcifications, that may or may not be a sign of cancer, may wish to have the lesion tested. For this, a sample of tissue (biopsy) needs to be taken from her breast to test for cancer. This recommendation evaluates the type of guidance used to obtain a sample using needle core biopsy.

When a suspicious lesion is detected in mammography screening, the woman is recalled for further assessment. This recommendation evaluates whether digital breast tomosynthesis or additional mammographic projections should be used for the diagnosis of the lesion.

Clip marking is a technique where a small device (2-3 mm) is placed in the breast tissue to locate where the excision needs to be made in women with breast cancer lesions. This recommendation evaluates the use of clip marking for surgical planning in these women.

The hormone receptor status of an invasive breast carcinoma may predict response to endocrine therapy. Different thresholds are currently being discussed to categorise a tumour as hormone receptor positive and to recommend endocrine therapy to those patients. The aim of these questions was to determine which is the most appropriate threshold to use.

Although mammography screening is recommended for women between the ages of 45 and 74 (and strongly recommended for women between the ages of 50 and 69), there is variation in practice with respect to offering them organised or non-organised screening. In 2003 the Council of the EU recommended the implementation of organised screening programmes. Currently, in most European countries that have screening, an organised screening programme is used (Giordano L et al., 2012). However, the two systems co-exist and as there are some uncertainties regarding their effectiveness the Guidelines Development Group issued this healthcare question.

One of the methods that has been adopted to improve sensitivity of mammography screening is double reading, whereby the mammograms are read, generally independently, by two trained readers. If every mammogram that is read as positive by one or both readers is recalled for assessment, this method has necessarily a detrimental impact on specificity. To mitigate or avoid this problem, mammograms with discordant readings can be reviewed by a third reader (arbitration) or can be discussed by the two readers to reach consensus. Another possible scenario for doing consensus is when the two readers agree on a positive result. Published articles addressing this topic, however, are missing. The main objective of this question is to determine whether a strategy in reading mammograms by double reading (independent or dependent, blinded or not) with a consensus conference (1st intervention) or double reading with arbitration (2nd intervention) is superior to single reading (comparison) with regards to different health outcomes.