Cancer Screening

Screening recommendations for individual patients vary according to their level of risk with higher risk patients requiring more frequent and sometimes more invasive management. Risk is not static and may change over time based on changes in both family and medical history.

Breast Cancer

Women at all risk levels should practice the following preventative behaviors:

  • Breast self-awareness
  • Healthy lifestyle
  • Clinical breast exam
  • Mammogram

Clinical breast exams and mammograms should be performed at different intervals depending on risk level, as indicated below. Breast ultrasound screening may also be indicated based on breast density. Clinical encounters should encompass ongoing risk assessment, risk reduction counseling and clinical breast exam. Guidelines change frequently and may differ. Please refer to guidelines for most recent information.     

Average Risk               

Screen based on age:  

  • Clinical encounter, including clinical breast exam: every 1-3 years, age 25-39
  • Clinical encounter and screening mammogram: annually, recommended or individualized beginning at age 40
Increased (Moderate) Risk                             

Screen with multiple modalities:

  • Clinical breast exam every 6-12 months
  • Mammogram: annual, beginning 10 years prior to youngest diagnosis in family but not prior to age 30
  • Breast MRI: annual, beginning 10 years prior to youngest diagnosis in family but not prior to age 25
  • Consider risk reduction strategies such as chemoprevention with Tamoxifen
  • Recommend cancer genetic counseling
High (Strong) Risk

Screen with multiple modalities:

  • Clinical breast exam every 6 months from age 25
  • Breast MRI: annual, from age 25-29 or individualized based on early onset (< age 30) family history
  • Mammogram and breast MRI: annual, beginning age 30 through age 75
  • Individualized for women > age 75
  • Consider risk reduction strategies such as chemoprevention with Tamoxifen
  • Consider prophylactic mastectomy
  • Recommend cancer genetic counseling

References

American Cancer Society (2007): ACS Guidelines for Breast Screening with MRI as an Adjunct to Mammography.

American College of Physicians (2019): Screening for Breast Cancer in Average-Risk Women: A Guidance Statement from the American College of Physicians.

National Comprehensive Cancer Network: Breast Cancer Screening and Diagnosis (v.1.2019), Breast Cancer Risk Reduction (v.1.2019), and Genetic/Familial High Risk Assessment: Breast, Ovarian and Pancreatic (v.1.2020). (Free registration required for access)

Ovarian Cancer

Women at all risk levels should practice the following preventative behaviors:

  • Ovarian cancer symptom awareness
Average Risk              
  • No current recommendations
Increased (Moderate) Risk                             
  • Consider chemoprevention, such as oral contraceptives
  • Recommend cancer genetic counseling
High (Strong) Risk
  • Consider chemoprevention, such as oral contraceptives
  • Advise on prophylactic bilateral salpingo-oophorectomy (BSO) between ages 35-45 (depending on genetic risk factors) and upon completion of childbearing (note: salpingectomy alone is not the standard of care for risk-reduction although clinical trials are ongoing)
  • For those who have notelected BSO, transvaginal ultrasound combined with serum CA-125, although of uncertain benefit, may be considered starting at age 30-35
  • Recommend cancer genetic counseling

References

National Comprehensive Cancer Network: Genetic/Familial High Risk Assessment: Breast, Ovarian and Pancreatic (v.1.2020), Genetic/Familial High Risk Assessment: Colorectal (v.3.2019). (Free registration required for access)

Colorectal Cancer

Average Risk
  • Screen for colorectal cancer at age 45 or 50 according to recognized guidelines
  • Advise that specific lifestyle changes may modify the risk for cancer
Increased (Moderate) Risk
  • Screening at earlier ages/more frequent intervals than average risk individuals (dependent on family/medical history and polyp burden)
  • Consider chemoprevention, such as aspirin
  • Update family history regularly (diagnosis of colon or a Lynch-related cancer* in one or more family members may change risk category)
  • Advise that specific lifestyle changes may modify the risk for cancer
  • Recommend cancer genetic counseling
High (Strong) Risk
  • Screen more frequently with colonoscopy and screen for related cancers (often annually) beginning in the 20s or earlier
  • Consider chemoprevention, such as aspirin
  • Consider prophylactic surgery as an option for risk reduction
  • Examine for other manifestations of hereditary syndromes
  • Advise that specific lifestyle changes may modify the risk for cancer
  • Recommend cancer genetic counseling

*Depending on the high risk CRC syndrome, related cancers may include endometrial, gastric, ovarian, prostate, and others. See the Genetically Related Cancers factsheet for more detail. 

References

American Cancer Society (2018): Colorectal Cancer Screening for Average-Risk Adults: 2018 Guideline Update.

American College of Gastroenterology (2015): Clinical Guideline on Genetic Testing and Management of Hereditary Gastrointestinal Cancer Syndromes.

American College of Physicians (2019): Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement for the American College of Physicians.

National Comprehensive Cancer Network: Genetic/Familial High Risk Assessment: Colorectal (v.3.2019), Colorectal Cancer Screening (v.2.2019). (Free registration required for access)

US Preventive Services Task Force (2016): Screening for Colorectal Cancer.

Prostate Cancer

Many professional societies and others have developed guidelines about the routine use of PSA and digital rectal exam (DRE) for prostate cancer screening. The information below provides a summary of the recommendations as is relevant to different risk levels. The majority of guidelines support facilitating informed decision making about whether to pursue PSA and/or DRE by discussing the benefits and limitations.

Average Risk

Asymptomatic men with a life expectancy of at least 10 years with average risk should receive information about the benefits and risks of prostate cancer screening starting at age 50 years.

Increased (Moderate) Risk and High (Strong) Risk

USPSTF defines older age, African American ethnicity and family history as factors that increase risk of prostate cancer. While recognizing these risk factors, USPSTF does not universally recommend enhanced PSA-based screening for those at increased risk. Before deciding to undergo screening, men age 55-69 should have an opportunity to discuss the potential benefits and harms of screening with their clinician and to incorporate their values and preferences in the decision.

ACP and ACS also recognize African-American men and men with a first-degree relative diagnosed with prostate cancer before age 65 years as having an elevated prostate cancer risk. ACP recommends that providers give these individuals information about uncertainties, risks and benefits of prostate cancer screening starting at age 45 years. ACS recommends starting the discussion for these individuals at age 40. 

ACP further states that men with African American race who have a first-degree relative diagnosed before 65 are at high risk and recommend starting the discussion about screening at age 40.

NCCN specifies specific follow-up guidelines for these individuals based on PSA levels.

References

American Cancer Society (2010): Guideline for Early Detection of Prostate Cancer.

American College of Physicians (2013): Screening for Prostate Cancer.

National Comprehensive Cancer Network: Prostate Cancer Early Detection (v.2.2019).(Free registration required for access)

US Preventive Services Task Force (2018): Prostate Cancer Screening.

Updated January 2020