The present day recommended screening procedures for breast cancer in women younger than 40 years of age are Clinical Breast Exam (CBE) and Self Breast Exam (SBE). For women over 40 in USA, the present day gold standard for breast cancer screening is Mammography (sometimes followed by Ultrasound and/or MRI).

The above is not true for developing countries like India where Mammography is not being promoted as a screening tool mainly due to the fact that more than 75% of the total population is younger than 50 years of age and adequate radiological infrastructure & radiologists are not available. Mammography is used for diagnostic purposes once a woman presents herself with symptoms.

Annual mammograms are recommended for women over 40 by American Cancer Society; some exceptions are made for symptomatic patients, patients with strong family history or genetic disposition. A mammogram induces a low-dose of X-ray to determine whether abnormal calcifications, growths or cysts are present.

Over the years many clinical facts have emerged specific to present day modalities such as mammography to understand its overall impact, benefits and risks:

• Mammography performs with low sensitivity and specificity for women with dense breasts. In a study by Rosenberg, screening mammograms were reviewed for changes in sensitivity due to age, breast density, ethnicity, and estrogen replacement therapy. Out of these screening mammograms 807 cancers were discovered at screening. The results showed that the sensitivity for mammography was 54% in women younger than 40, 77% in women aged 40–49, 78% in women aged 50–64, and 81% in women older than 64 years. Sensitivity was 68% in women with dense breasts and 74% in estrogen replacement therapy users.
• Investigating the cumulative risk of a false-positive result in mammographic screening, Elmore and associates performed a 10-year retrospective study of 2400 women, 40 to 69 years of age. A total of 9762 mammograms were investigated. It was found that a woman had an estimated 49.1% cumulative risk of having a false-positive result after 10 mammograms. Even though no breast cancer was present, over one-third of the women screened were required to have additional evaluations.
• Mammography often causes discomfort to women due to the compression of breasts between plates and may deter women from screening.
• Mammography incorporates X-rays; which exposes women to a low dose of radiation which is concerning in younger women (under 40) in regards to increased lifetime exposure.
• Ultrasound is greatly user dependent, not readily available and carries a high rate of false positive results.
• MRI is a very expensive procedure, is not portable and performs with low specificity to detect small carcinomas and DCIS. Currently MRI exams may not be suitable for widespread, population-based screening.
• Currently, Clinical Breast Exam (CBE) is the primary method for general breast cancer screening for younger pre-menopausal women.

Following are some of CBE’s shortfalls:

• CBE tends to detect breast cancer at a later stage than Mammography and proves to be less sensitive than Mammography, detecting about 10-15% of the carcinomas identified by mammography.
• CBE is a manual exam and hence is examiner dependent. CBE has difficulty in monitoring the growth of breast cancer starting from an early stage.
• Regular BSE is not an effective method of reducing breast cancer mortality.

References may be provided upon request.