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prev.breast-cancer-screening.v1

Preventive breast-cancer screening (adult)

general_internal_medicinechronicadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm preventive breast-screening scope: asymptomatic woman/AFAB, age 40-74, life expectancy ≥10 yr. Excludes diagnostic workup of a palpable mass / nipple discharge / skin change (those = a different, higher prior → diagnostic pathway) and prior-breast-cancer survivorship surveillance (USPSTF 2024 PMID 38687503; ACS 2015 PMID 26501536)

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4
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Advance rule
Set
Advance when

Asymptomatic, eligible 40-74, ≥10-yr life expectancy confirmed; no palpable finding (else exit to diagnostic)

Patient inputs (13)

Dense breasts (BI-RADS C/D) lower mammography sensitivity (test-characteristic shift / masking) → interval cancers; drives supplemental-imaging consideration (USPSTF 2024 I-statement PMID 38687503; DENSE PMID 31774954)

Age sets pre-test prevalence (the Bayesian prior) and the 40-74 eligibility window (USPSTF 2024 PMID 38687503)

Breast screening applies to women and all persons assigned female at birth at average risk (USPSTF 2024 PMID 38687503)

Prior mammogram dates + BI-RADS set the next interval and the conditional post-test prior (USPSTF 2024)

Screening benefit requires ≥10-yr life expectancy; below that lead-time + overdiagnosis harm exceeds benefit → STOP-screening logic (USPSTF 2024 I-statement ≥75; ACS 2015 PMID 26501536)

BRCA1/2 (lifetime breast risk ~55-72%), Li-Fraumeni TP53 — very high prior → annual MRI + mammography from age 25-30 (NCCN; ACS 2015)

First-degree relative with breast/ovarian cancer raises the pre-test prior and is a Tyrer-Cuzick/Gail input — shifts age/modality (ACS 2015 PMID 26501536)

Mantle/chest radiation age 10-30 → very high breast prior → annual MRI + mammo from age 25-30 (ACS 2015 PMID 26501536; NCCN)

Pregnancy defers routine screening mammography to postpartum unless a clinical finding mandates diagnostic imaging — special-population branch

Prior breast-cancer survivors follow survivorship surveillance imaging, not average-risk screening — different prior + protocol (NCCN survivorship)

Palpable mass / focal pain / nipple discharge / skin change = a different (much higher) prior → DIAGNOSTIC pathway, NOT average-risk screening (USPSTF 2024 scope)

Premenopausal → tamoxifen for chemoprevention; postmenopausal → raloxifene or aromatase inhibitor (USPSTF 2019; Cuzick PMID 23639488; Goss MAP.3 PMID 21639806)

Prior VTE / concurrent anticoagulation contraindicates SERM chemoprevention (Cuzick meta-analysis VTE OR 1.73 PMID 23639488)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationalseverebirads_4_5_high_PPV_route_to_biopsy — ACR BI-RADS
    BI-RADS 4 (PPV ~2-95%) or 5 (PPV ≥95%) — post-test probability now high enough that the harm of NOT biopsying exceeds the harm of the diagnostic core-biopsy cascade
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehereditary_breast_cancer_syndrome_confirmed — NCCN/ACS 2015
    Confirmed BRCA1/2 (lifetime breast risk ~55-72%), Li-Fraumeni TP53, or prior chest radiation age 10-30 — very high prior requiring earlier (age 25-30) + more frequent (annual MRI + mammography) surveillance
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepalpable_mass_is_diagnostic_not_screening — USPSTF scope
    Palpable breast mass, bloody/spontaneous nipple discharge, skin retraction/peau d'orange, or focal persistent pain — a fundamentally different (much higher) prior than asymptomatic screening
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterisk_model_crosses_action_threshold_intensify — Tyrer-Cuzick/Gail
    Tyrer-Cuzick/IBIS lifetime ≥20% (→ add annual MRI) or Gail/BCRAT 5-yr ≥1.67% (→ chemoprevention) — the calculated risk-model output IS the pre-test prior and it crosses the action threshold
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedense_breast_lowers_mammography_sensitivity — DENSE/USPSTF 2024
    BI-RADS C/D dense breasts mask tumors → mammography sensitivity falls (a conditional dependency: sensitivity covaries inversely with density); interval-cancer risk rises. Supplemental MRI considered for extremely dense + negative mammogram
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefalse_positive_cascade_and_overdiagnosis_harm — CISNET
    A positive screen in a lower-prior context (e.g., age 40-49) is more likely a false-positive recall or overdiagnosed; CISNET: biennial DBT 40-74 = 1376 false-positive recalls + 14 overdiagnosed cases / 1000 women screened — the harm side of the Bayesian ledger
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildprior_below_testing_threshold_do_not_screen — USPSTF 2024 / ACS 2015
    Age <40 average-risk, age >74 (USPSTF 2024 I-statement — evidence insufficient ≥75), or life expectancy <10 yr — pre-test prevalence × harm of the false-positive recall cascade + overdiagnosis exceeds expected mortality benefit
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildstop_screening_age_or_life_expectancy_bound — USPSTF 2024 / ACS 2015
    Age >74 (USPSTF 2024 I-statement) OR life expectancy <10 yr — the deprescribing-equivalent: lead-time + overdiagnosis harm now exceeds mortality benefit
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

Breast — mammography/DBT ± supplemental MRI + chemoprevention (USPSTF 2024 Grade B biennial 40-74 PMID 38687503; CISNET PMID 38687505; USPSTF 2019)
axis: screening_modality_breast
Selected axis "Breast — mammography/DBT ± supplemental MRI + chemoprevention (USPSTF 2024 Grade B biennial 40-74 PMID 38687503; CISNET PMID 38687505; USPSTF 2019)" by default fallback (first axis)
  • screening_mammography_biennial_40_74
    first line
    imaging_screen
    Biennial digital mammography, age 40-74 • imaging • q2yr
    USPSTF 2024 (Nicholson JAMA 2024 PMID 38687503) Grade B biennial 40-74 — moderate net benefit; CISNET (Trentham-Dietz JAMA 2024 PMID 38687505): biennial DBT 40-74 = 30.0% breast-ca mortality reduction, 8.2 deaths averted/1000, 1376 false-positive recalls + 14 overdiagnosed/1000. UK Age RCT (Duffy HTA 2020 PMID 33141657): intervention-phase mortality RR 0.75 (25%↓, 95% CI 0.58-0.97) at 10 yr, ~1 death/1000.
  • digital_breast_tomosynthesis_dbt
    first line
    imaging_screen
    Biennial DBT/tomosynthesis age 40-74 (preferred where available) • imaging • q2yr
    triggers: dbt_available
    DBT: similar mortality benefit to digital mammography with FEWER false-positive recalls; Svahn meta-analysis (Breast 2015 PMID 26433751) FP:TP ratio 2D→2D/3D improved 30-55% (STORM 5.96→3.17; Oslo 10.25→7.07). CISNET PMID 38687505 used DBT as the modeled modality.
  • supplemental_breast_mri_high_risk
    comorbidity specific
    imaging_screen
    Annual MRI + mammography from age 25-30 (or 10 yr before youngest FDR dx) • imaging • annual
    triggers: tyrer_cuzick_lifetime_ge_20pct, BRCA1_or_BRCA2, chest_radiation_age_10_to_30, li_fraumeni_TP53
    ACS 2015 (Oeffinger JAMA 2015 PMID 26501536) / NCCN — lifetime ≥20% (Tyrer-Cuzick) or BRCA/TP53/mantle-RT prior is high enough that MRI sensitivity gain net-benefits. DENSE RCT (Bakker NEJM 2019 PMID 31774954): supplemental MRI in extremely dense breasts cut interval cancers 5.0→2.5/1000 (Δ2.5, 95% CI 1.0-3.7).
  • tamoxifen
    comorbidity specific
    SERM
    20 mg • PO • daily × 5 yr
    triggers: gail_5yr_risk_ge_1_67pct, premenopausal_high_risk
    USPSTF 2019 risk-reducing therapy when Gail/BCRAT 5-yr ≥1.67%; Cuzick SERM meta-analysis (Lancet 2013 PMID 23639488) breast-ca incidence HR 0.62 (38%↓), NNT 42/10 yr, VTE OR 1.73. RxCUI 10324 RxNav-verified 2026-05-16 — NEEDS_RXNAV_VALIDATION.
    rxcui 10324
  • raloxifene
    comorbidity specific
    SERM
    60 mg • PO • daily × 5 yr
    triggers: gail_5yr_risk_ge_1_67pct, postmenopausal_high_risk
    USPSTF 2019; included in Cuzick SERM meta-analysis (PMID 23639488 HR 0.62) — postmenopausal, lower VTE/endometrial risk than tamoxifen. RxCUI 72143 RxNav-verified by name lookup 2026-05-16 (parent dossier 72567 was STALE) — NEEDS_RXNAV_VALIDATION.
    rxcui 72143
  • exemestane
    second line
    aromatase_inhibitor
    25 mg • PO • daily × 5 yr
    triggers: postmenopausal_high_risk_SERM_intolerant
    MAP.3 RCT (Goss NEJM 2011 PMID 21639806): invasive breast-ca 0.19% vs 0.55%, HR 0.35 (65%↓, 95% CI 0.18-0.70); musculoskeletal/bone harm; second-line postmenopausal chemoprevention (USPSTF 2019). RxCUI 258494 RxNav-verified by name lookup 2026-05-16 — NEEDS_RXNAV_VALIDATION.
    rxcui 258494
  • anastrozole
    second line
    aromatase_inhibitor
    1 mg • PO • daily × 5 yr
    triggers: postmenopausal_high_risk_SERM_intolerant, exemestane_intolerant
    Aromatase-inhibitor chemoprevention alternative (IBIS-II analogue) postmenopausal high-risk; class effect mirrors MAP.3 exemestane (Goss PMID 21639806). RxCUI 84857 RxNav-verified 2026-05-16 (tty IN) — NEEDS_RXNAV_VALIDATION.
    rxcui 84857

outpatient playbook — drug actions (2)

  1. 1. tamoxifen 20 mg (premenopausal) or raloxifene 60 mg (postmenopausal) daily × 5 yr
    rxcui 10324
    20 mg (tamoxifen) / 60 mg (raloxifene) • PO • daily
    trigger: Gail/BCRAT 5-yr risk ≥1.67% and shared decision (USPSTF 2019; Cuzick HR 0.62 PMID 23639488)
    Breast-cancer risk-reducing therapy; weigh VTE/endometrial harm (USPSTF 2019; Cuzick VTE OR 1.73 PMID 23639488)
  2. 2. exemestane 25 mg (or anastrozole 1 mg) daily × 5 yr
    rxcui 258494
    25 mg (exemestane) / 1 mg (anastrozole) • PO • daily
    trigger: Postmenopausal high-risk, SERM-intolerant (USPSTF 2019; Goss MAP.3 HR 0.35 PMID 21639806)
    Aromatase-inhibitor chemoprevention — 65% relative reduction invasive breast cancer; musculoskeletal/bone harm (MAP.3 PMID 21639806)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Routine preventive/wellness visit — breast screening due (USPSTF 2024 biennial 40-74 Grade B PMID 38687503); Known hereditary risk (BRCA1/2, Li-Fraumeni TP53, prior chest RT age 10-30) requiring intensified MRI surveillance (ACS 2015 PMID 26501536; NCCN); Overdue or never-screened woman/AFAB identified at any encounter (USPSTF 2024).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Preventive breast-cancer screening (adult)** (prev.breast-cancer-screening.v1).
Phenotype framing: Average-risk vs high-risk pathway, AND true-positive (early invasive carcinoma / DCIS) vs false-positive (dense-tissue masking artifact, benign fibroadenoma, simple/complex cyst, fat necrosis) — the false-positive recall cascade and overdiagnosis are encoded as harm DATA, not prose (CISNET: 1376 FP recalls + 14 overdiagnosed / 1000 biennial DBT 40-74 PMID 38687505). Screen-detected positive routes to biopsy/dx; screen-negative returns to interval
Scope: Confirm preventive breast-screening scope: asymptomatic woman/AFAB, age 40-74, life expectancy ≥10 yr. Excludes diagnostic workup of a palpable mass / nipple discharge / skin change (those = a different, higher prior → diagnostic pathway) and prior-breast-cancer survivorship surveillance (USPSTF 2024 PMID 38687503; ACS 2015 PMID 26501536)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Breast — mammography/DBT ± supplemental MRI + chemoprevention (USPSTF 2024 Grade B biennial 40-74 PMID 38687503; CISNET PMID 38687505; USPSTF 2019)**.
1. screening_mammography_biennial_40_74 Biennial digital mammography, age 40-74 imaging q2yr (imaging_screen, first line) — USPSTF 2024 (Nicholson JAMA 2024 PMID 38687503) Grade B biennial 40-74 — moderate net benefit; CISNET (Trentham-Dietz JAMA 2024 PMID 38687505): biennial DBT 40-74 = 30.0% breast-ca mortality reduction, 8.2 deaths averted/1000, 1376 false-positive recalls + 14 overdiagnosed/1000. UK Age RCT (Duffy HTA 2020 PMID 33141657): intervention-phase mortality RR 0.75 (25%↓, 95% CI 0.58-0.97) at 10 yr, ~1 death/1000.
2. digital_breast_tomosynthesis_dbt Biennial DBT/tomosynthesis age 40-74 (preferred where available) imaging q2yr (imaging_screen, first line) — DBT: similar mortality benefit to digital mammography with FEWER false-positive recalls; Svahn meta-analysis (Breast 2015 PMID 26433751) FP:TP ratio 2D→2D/3D improved 30-55% (STORM 5.96→3.17; Oslo 10.25→7.07). CISNET PMID 38687505 used DBT as the modeled modality.
3. supplemental_breast_mri_high_risk Annual MRI + mammography from age 25-30 (or 10 yr before youngest FDR dx) imaging annual (imaging_screen, comorbidity specific) — ACS 2015 (Oeffinger JAMA 2015 PMID 26501536) / NCCN — lifetime ≥20% (Tyrer-Cuzick) or BRCA/TP53/mantle-RT prior is high enough that MRI sensitivity gain net-benefits. DENSE RCT (Bakker NEJM 2019 PMID 31774954): supplemental MRI in extremely dense breasts cut interval cancers 5.0→2.5/1000 (Δ2.5, 95% CI 1.0-3.7).
4. tamoxifen 20 mg PO daily × 5 yr (SERM, comorbidity specific) — USPSTF 2019 risk-reducing therapy when Gail/BCRAT 5-yr ≥1.67%; Cuzick SERM meta-analysis (Lancet 2013 PMID 23639488) breast-ca incidence HR 0.62 (38%↓), NNT 42/10 yr, VTE OR 1.73. RxCUI 10324 RxNav-verified 2026-05-16 — NEEDS_RXNAV_VALIDATION.
5. raloxifene 60 mg PO daily × 5 yr (SERM, comorbidity specific) — USPSTF 2019; included in Cuzick SERM meta-analysis (PMID 23639488 HR 0.62) — postmenopausal, lower VTE/endometrial risk than tamoxifen. RxCUI 72143 RxNav-verified by name lookup 2026-05-16 (parent dossier 72567 was STALE) — NEEDS_RXNAV_VALIDATION.
6. exemestane 25 mg PO daily × 5 yr (aromatase_inhibitor, second line) — MAP.3 RCT (Goss NEJM 2011 PMID 21639806): invasive breast-ca 0.19% vs 0.55%, HR 0.35 (65%↓, 95% CI 0.18-0.70); musculoskeletal/bone harm; second-line postmenopausal chemoprevention (USPSTF 2019). RxCUI 258494 RxNav-verified by name lookup 2026-05-16 — NEEDS_RXNAV_VALIDATION.
7. anastrozole 1 mg PO daily × 5 yr (aromatase_inhibitor, second line) — Aromatase-inhibitor chemoprevention alternative (IBIS-II analogue) postmenopausal high-risk; class effect mirrors MAP.3 exemestane (Goss PMID 21639806). RxCUI 84857 RxNav-verified 2026-05-16 (tty IN) — NEEDS_RXNAV_VALIDATION.

Setting playbook (outpatient) — Set the pre-test prevalence prior (age/density/family-hx/risk-model), order the age/risk-appropriate screen (DM vs DBT vs supplemental MRI), apply BI-RADS PPV reasoning to positives, route follow-up, document modality + shared decision + harms, schedule recall, and apply STOP-screening logic when harm exceeds benefit (USPSTF 2024 PMID 38687503; CISNET PMID 38687505; ACS 2015 PMID 26501536)
8. tamoxifen 20 mg (premenopausal) or raloxifene 60 mg (postmenopausal) daily × 5 yr 20 mg (tamoxifen) / 60 mg (raloxifene) PO daily — Gail/BCRAT 5-yr risk ≥1.67% and shared decision (USPSTF 2019; Cuzick HR 0.62 PMID 23639488) (Breast-cancer risk-reducing therapy; weigh VTE/endometrial harm (USPSTF 2019; Cuzick VTE OR 1.73 PMID 23639488))
9. exemestane 25 mg (or anastrozole 1 mg) daily × 5 yr 25 mg (exemestane) / 1 mg (anastrozole) PO daily — Postmenopausal high-risk, SERM-intolerant (USPSTF 2019; Goss MAP.3 HR 0.35 PMID 21639806) (Aromatase-inhibitor chemoprevention — 65% relative reduction invasive breast cancer; musculoskeletal/bone harm (MAP.3 PMID 21639806))

Non-pharmacologic actions:
- Order biennial digital mammography or DBT age 40-74; DBT preferred where available — fewer FP recalls (USPSTF 2024 PMID 38687503; CISNET PMID 38687505; Svahn PMID 26433751)
- Add annual MRI + mammography from age 25-30 if Tyrer-Cuzick lifetime ≥20% / BRCA / Li-Fraumeni / chest-RT (ACS 2015 PMID 26501536; DENSE PMID 31774954)
- Apply BI-RADS PPV: 0 → recall additional views/US; 1/2 → routine interval; 3 → 6-mo short-interval; 4/5 → image-guided core biopsy; 6 → oncology (ACR BI-RADS)
- Refer to genetics if BRCA/Li-Fraumeni criteria met (USPSTF 2019; NCCN)
- Patient education: density-shifted sensitivity, BI-RADS PPV, false-positive recall cascade (CISNET 1376/1000 biennial DBT 40-74), overdiagnosis (~14/1000), value of stopping when harm dominates (USPSTF 2024 PMID 38687503; CISNET PMID 38687505)

AVOID / contraindication checks:
- Stop_routine_mammography_after_age_74_evidence_insufficient (USPSTF 2024 I statement PMID 38687503)
- No_routine_average_risk_screening_lt_age_40 (USPSTF 2024 — below this the FP recall + overdiagnosis harm dominates PMID 38687503)
- Avoid_screening_if_life_expectancy_lt_10yr (ACS 2015 PMID 26501536 — lead time + overdiagnosis harm exceeds benefit)
- Tamoxifen_contraindicated_hx_VTE_or_concurrent_anticoag (USPSTF 2019; Cuzick VTE OR 1.73 PMID 23639488)
- Aromatase_inhibitor_only_postmenopausal (USPSTF 2019; Goss MAP.3 PMID 21639806)
- Avoid_chemoprevention_if_life_expectancy_lt_10yr (USPSTF 2019)
- Special_pop:dense_breast_supplemental_us_or_mri_is_I_statement_individualize (USPSTF 2024 I statement PMID 38687503; DENSE evidence for extremely dense + neg mammogram PMID 31774954)
- Special_pop:high_risk_BRCA_TC20_chestRT_annual_MRI_plus_mammo_from_age_25_30 (ACS 2015 PMID 26501536; NCCN)
- Special_pop:palpable_mass_or_nipple_discharge_is_diagnostic_not_screening (different/higher prior — exit to diagnostic pathway)
- Special_pop:pregnancy_defer_routine_screening_mammography_to_postpartum_unless_clinical_finding
- Special_pop:prior_breast_cancer_use_survivorship_imaging_not_average_risk_screening (NCCN survivorship)

Monitoring

Regimen monitoring:
- biennial mammography or dbt age 40 to 74 (USPSTF 2024 PMID 38687503)
- annual mammography plus MRI if tyrer cuzick lifetime ge 20pct (ACS 2015 PMID 26501536)
- birads structured reporting PPV by category 0 recall 3 short interval 4 5 biopsy (ACR BI-RADS)
- stop screening review age gt 74 or life expectancy lt 10yr (USPSTF 2024 I-statement; ACS 2015 PMID 26501536)
- chemoprevention 5yr course with vte endometrial surveillance if threshold met (USPSTF 2019; Cuzick PMID 23639488)

Setting (outpatient) monitoring:
- Biennial mammography/DBT age 40-74 (USPSTF 2024 PMID 38687503)
- Annual mammography + MRI if lifetime risk ≥20% (ACS 2015 PMID 26501536)
- BI-RADS structured recall by category (ACR BI-RADS)
- Chemoprevention 5-yr course with VTE/endometrial surveillance if threshold met (USPSTF 2019)
- Stop-screening review age >74 or life expectancy <10 yr (USPSTF 2024 I-statement; ACS 2015 PMID 26501536)

Follow-up plan: STOP-screening / deprescribing-equivalent: discontinue when life expectancy <10 yr OR age >74 (USPSTF 2024 I-statement — evidence insufficient ≥75; ACS 2015 continue while ≥10-yr life expectancy PMID 26501536). Genetic-counseling referral if criteria met. Chemoprevention follow-up. Patient education on the false-positive recall cascade (CISNET 1376/1000 biennial DBT 40-74) and overdiagnosis (~14/1000) — the harm side of the Bayesian ledger (USPSTF 2024 PMID 38687503; CISNET PMID 38687505)
- Close-out criterion: Stop-screening decision OR continued-interval education delivered and documented

Monitoring phase: Interval + recall: biennial mammography/DBT age 40-74 (USPSTF 2024 Grade B PMID 38687503); annual mammography + MRI if Tyrer-Cuzick lifetime ≥20% (ACS 2015 PMID 26501536); BI-RADS structured reporting with category-specific recall (3 → 6-mo short-interval; 0 → prompt additional imaging)

Disposition

Current setting: outpatient — Set the pre-test prevalence prior (age/density/family-hx/risk-model), order the age/risk-appropriate screen (DM vs DBT vs supplemental MRI), apply BI-RADS PPV reasoning to positives, route follow-up, document modality + shared decision + harms, schedule recall, and apply STOP-screening logic when harm exceeds benefit (USPSTF 2024 PMID 38687503; CISNET PMID 38687505; ACS 2015 PMID 26501536)

Disposition criteria:
- Continue per interval if BI-RADS 1/2 and still eligible (USPSTF 2024 PMID 38687503)
- Refer to breast surgery/oncology for BI-RADS 4/5 or biopsy-proven cancer (ACR BI-RADS)
- STOP screening when life expectancy <10 yr or age >74 — deprescribing-equivalent (USPSTF 2024 I-statement; ACS 2015 PMID 26501536)

Escalation triggers (move to higher acuity):
- BI-RADS 4-5 → breast surgery/biopsy (ACR BI-RADS; USPSTF 2024 PMID 38687503)
- Biopsy-proven malignancy → breast oncology / multidisciplinary tumor board
- Hereditary syndrome confirmed → NCCN high-risk protocol + cascade testing (NCCN)
- Palpable mass / bloody nipple discharge / skin change → diagnostic breast imaging, NOT screening interval

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] BI-RADS 4 (PPV ~2-95%) or 5 (PPV ≥95%) — post-test probability now high enough that the harm of NOT biopsying exceeds the harm of the diagnostic core-biopsy cascade
- [SEVERE] Confirmed BRCA1/2 (lifetime breast risk ~55-72%), Li-Fraumeni TP53, or prior chest radiation age 10-30 — very high prior requiring earlier (age 25-30) + more frequent (annual MRI + mammography) surveillance
- [SEVERE] Palpable breast mass, bloody/spontaneous nipple discharge, skin retraction/peau d'orange, or focal persistent pain — a fundamentally different (much higher) prior than asymptomatic screening

Citations

- USPSTF 2024 breast-cancer screening recommendation statement (biennial mammography 40-74 Grade B; ≥75 I-statement; dense-breast supplemental I-statement) + CISNET collaborative modeling decision analysis; ACS 2015 breast guideline; USPSTF 2019 risk-reducing medications [PMID:38687503](https://pubmed.ncbi.nlm.nih.gov/38687503/)
- Cited evidence (PMID 38687505) [PMID:38687505](https://pubmed.ncbi.nlm.nih.gov/38687505/)
- Cited evidence (PMID 33141657) [PMID:33141657](https://pubmed.ncbi.nlm.nih.gov/33141657/)
- Cited evidence (PMID 31774954) [PMID:31774954](https://pubmed.ncbi.nlm.nih.gov/31774954/)
- Cited evidence (PMID 26433751) [PMID:26433751](https://pubmed.ncbi.nlm.nih.gov/26433751/)

Last reconciled with current guidelines: 2026-05-16.
References
  • USPSTF 2024 breast-cancer screening recommendation statement (biennial mammography 40-74 Grade B; ≥75 I-statement; dense-breast supplemental I-statement) + CISNET collaborative modeling decision analysis; ACS 2015 breast guideline; USPSTF 2019 risk-reducing medications — PMID:38687503
  • Cited evidence (PMID 38687505) — PMID:38687505
  • Cited evidence (PMID 33141657) — PMID:33141657
  • Cited evidence (PMID 31774954) — PMID:31774954
  • Cited evidence (PMID 26433751) — PMID:26433751