The goal of breast cancer screening is to reduce morbidity and mortality by detecting cancer at its earliest possible stage, before
it causes any symptoms or complaints. Early stage cancer is more likely to be
treated successfully and with less aggressive treatments. The traditional approach to breast cancer screening has been threefold: mammography, clinical breast examination, and breast self-exam. Currently, the mainstay remains mammography.
of Early Detection
Between 1990 and 2008, the mortality
rate from breast cancer declined by 2.2%
decrease is largely attributed to earlier detection through screening and improved treatments.2 When breast cancer is detected and treated at a
localized stage (confined to the breast), the 5-year relative survival rate for women of all races combined is 99%. For regional disease, the rate is 84%. If
breast cancer has spread to distant organs, 5-year survival
drops to 23%.3
Source: Adapted from NCI Visuals Online. AV-9004-4088.
Regular screening with mammography has consistently been found to reduce breast cancer-related deaths.45 Moreover,
women whose breast cancer is detected by screening
mammography are more likely to be adequately treated
with less toxic therapy, such as breast conservation
and without chemotherapy.6 Despite
these significant benefits, many U.S. women do not
get regular mammograms. While individual reasons vary,
concerns about screening costs and the expense of diagnostic
procedures have been
recognized as barriers.
The Breast and Cervical Cancer Mortality
Prevention Act of 1990
To help improve access to breast cancer screening for low-income and uninsured women, Congress passed the Breast and Cervical Cancer Mortality Prevention Act of 1990 which created Centers for Disease Control and Prevention's (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP). This program provides both screening and diagnostic services, including clinical breast examinations, mammograms, pap tests, pelvic examinations, and diagnostic testing for women whose screening outcomes are abnormal. The text of the legislation that established the program, its amendments, and other related legislation can be found on the CDC website.
NBCCEDP operates in all 50 states, the District of Columbia, 5 U.S. territories, and 12 American Indian/Alaska Native organizations. Since 1991, programs funded by NBCCEDP have served more than 4.2 million women, provided more than 10.4 million breast and cervical cancer screening examinations, and diagnosed more than 54,276 breast cancers.7
In California, this NBCCEDP-funded program is called Every Woman Counts (EWC). It is facilitated by the Department of Health Care Services (DHCS). For additional information about EWC, please refer to the EWC Program section of this website, or visit the EWC section on Department of Health Care Services website.
The Mammography Quality Standards
Act (MQSA) of 1992
The regulation of mammography
is outlined by federal law.
The regulation of mammography is outlined by federal law. The Mammography Quality Standards Act (MQSA) of 1992 requires that all mammography facilities in the U.S. meet stringent quality standards. The FDA is charged by Congress with developing and implementing MQSA regulations which also apply to facility personnel (e.g., radiologists, radiologic technologists, and medical physicists). Additional information about MSQA and FDA-certified mammography facilities is available on the website of the U.S. Food and Drug Administration.
Guidelines for breast cancer screening
are revised regularly to take into account new research
findings and developments. Currently, there is a lack of consensus with regard to optimal ages for beginning and ending screening, and how frequently to screen. Guidelines also differ in their recommendations for the use of clinical breast examination (CBE) and breast self-examination (BSE). Screening guidelines by the U.S. Preventive Services Task Force (USPSTF) and American Cancer Society (ACS), and the American College of Obstetricians and Gynecologists (ACOG) are highlighted below. For the most recent recommendations of other major guideline developers (e.g.,, American College of Physicians (ACP), Kaiser Permanente), please refer to the website of the National Guideline Clearinghouse.
U.S. Preventive Services Task Force (USPSTF) Guidelines (2009)
The USPSTF recommends biennial screening mammography, beginning at age 50 for women with average risk. The guideline authors state that the decision to start mammography screening before the age of 50 should be an individual one and take into account the patient's situation, including her values regarding the benefits and harms of screening. For older women, the USPSTF believes that the current evidence is insufficient for assessing the additional benefits and harms of screening mammography in women past age 74. Similarly, with regard to clinical breast examination (CBE), the USPSTF believes that there is insufficient evidence for assessing the additional benefits of CBE beyond screening mammography in women 40 years or older. The USPSTF recommends against clinicians teaching women how to perform BSE, stating that adequate evidence suggests that teaching BSE does not reduce breast cancer mortality. Last, the UPSPTF has determined that evidence is insufficient for
assessing the additional benefits and harms
of MRI as a screening
method for breast cancer.8
American Cancer Society (ACS) Guidelines (2015)
For women with average risk, the ACS recommends that they undergo annual screening mammography between the ages of 45-54 and transition to biennial screening at the age of 55 with the option of continuing to screen annually. In addition, the guidelines suggest that women should be offered the option of beginning annual screening at the age of 40 and that screening should continue as long as women are in good health with a life expectancy of at least 10 years. The ACS does not recommend clinical breast exam for breast cancer screening for women of any age. For certain women at high risk for breast cancer, ACS recommends screening with magnetic resonance imaging (MRI) as an adjunct to mammography. 9
American College of Obstetricians and Gynecologists (ACOG) Guidelines (2011)
ACOG recommends annual screening mammography for women 40 years and older; beginning at age 75, women should consult with their physicians to decide whether or not to continue with mammographic screening and should consider medical comorbidities and life expectancy. ACOG supports the use of clinical breast exam as a screening tool and recommends that women 40 and older have annual CBE, while women ages 20-39 have a CBE every one to three years. ACOG is in favor of considering teaching high-risk women breast self-examination and recommends that all women be taught about breast self-awareness.10
Comparison of USPSTF, ACS, and ACOG
Biennial screening mammography beginning at age 50.
Annual screening mammography beginning at age 45 with an option to begin at age 40. Transition to biennial screening at age 55 with option to continue annual screening.
Annual Screening Mammography beginning at age 40.
Evidence is insufficient for assessing the additional benefits of screening mammography in women past age 74.
Continue biennial screening mammography for as long as a woman is in good health and a life expectancy of has at least 10 years.
Women aged 75 years and older should consult with their physicians to decide whether or not to continue screening mammography.
Recommends against clinicians teaching women how to perform breast self-examination.
Recommends against clinicians teaching women how to perform breast self-examination.
Consider breast self-examination instruction for high-risk patients. Breast self-awareness should be encouraged and can include breast self-examination.
Evidence is insufficient for assessing the additional benefits of clinical breast examination beyond screening mammography in women 40 years and older.
CBE not recommended for average risk women at any age.
CBE should be performed annually for women aged 40 and older. For women 20-39 years of age, CBE recommended every 1-3 years.
Evidence is insufficient for assessing the additional benefits and harms of MRI as a screening method for breast cancer.
In addition to screening mammography, annual MRI screening is recommended for women with greater than 20% lifetime risk of breast cancer.
MRI not recommended for average risk women. For those women who have BCRA1 or BRCA2 mutations and for those women with greater than 20% lifetime risk of breast cancer, enhanced screening should be offered.
Information for Every Woman Counts (EWC) Providers
Every Woman Counts pays for screening mammograms for women starting at age 40 once a year. EWC recommends that every EWC beneficiary discuss screening guidelines with her physician. Together, they should make an individual decision about the age of initiation and frequency of screening based on the woman’s risk of breast cancer and her personal beliefs about the risks and benefits of screening.
A screening mammogram uses a low-dose X-ray system to detect breast cancer in women
who have no signs or symptoms. With an average sensitivity and specificity of approximately 84% and 90%, respectively, it is the most effective method used for detecting breast cancer early.11
Source: Bill Branson (photographer). Adapted from NCI Visuals Online. AV-9101-3981.
A standard screening mammogram consists
of two views of each breast, the craniocaudal (CC)
projection and the mediolateral oblique (MLO) projection. Additional
views may be needed for women with breast implants.
and abnormal findings are classified in accordance
with the Breast Imaging Reporting and Data System (BI-RADS®).12 The
accuracy of mammography depends upon the skill of the
technologist who takes the mammogram, the radiologist
who interprets the mammogram, and the use of well-calibrated,
Film vs. Digital Mammography
Film mammography (also called conventional mammography, or conventional film screen mammography) has been used for over 35 years. The first use of digital mammography in the clinical setting is more recent, beginning with FDA approval in 2000. Both film and digital mammography use low dose X-rays to produce an image of the breast. For the patient, the experience is identical.
With film mammography, the image is recorded directly on film. Digital mammography records the image electronically and stores it directly on to a computer (as with a digital camera). Because digital images can be adjusted, subtle differences
between normal and abnormal tissues may be more easily noted. Digital images can also be shared electronically which make long-distance
consultations between health providers more efficient.
Research has found that digital mammography may be somewhat better than film at finding cancers in women with dense breasts.13 It may also offer a small screening advantage in women younger than 50 years of age.4 Additionally, some studies have suggested that digital mammography is associated with lower doses of radiation than film mammography, and that the reduction could be greater in women with larger and denser breasts.14
Nevertheless, numerous studies comparing the performance of digital and film screen mammography have found little difference in cancer detection rates.4 Moreover, the National Cancer Institute notes that "to date there is no evidence that digital mammography helps to further reduce a woman's risk of dying from breast cancer."15 In summary, medical experts have determined that "film mammography remains an acceptable screening modality for all women."4
Information for Every Woman Counts (EWC) Providers
Assembly member Pedro Nava introduced AB 359 to authorize Medi-Cal reimbursement of digital mammography screening. The bill was signed into law by Governor Arnold Schwarzenegger in October, 2009. AB 359 (Revenue and Taxation Code: Section 30461-30462.1, Chapter 435) requires EWC to reimburse for digital mammography (DM).
Computer-Aided Detection (CAD) may be used with either film or digital mammograms. It involves the use of computer software to bring
suspicious areas on a mammogram to the radiologist’s
attention. Some research suggests that
this technology may slightly increase the sensitivity of mammography but at the expense of decreased specificity with higher rates of recall. Despite its increasingly widespread use (nearly three of four screening mammograms in the U.S. now involve the use of CAD), debate exists regarding its benefits, and whether these
outweigh its potential risks and costs.16
Information for Every Woman Counts (EWC) Providers
To date, there is no scientific evidence to demonstrate that the use of CAD reduces morbidity and mortality associated with the detection of breast cancer. NBCCEDP and EWC do not provide payment for CAD.
Tomosynthesis (also called 3D mammography) builds upon the technology of digital mammography. Using conventional X-rays, tomosynthesis takes dozens of thin cross-sectional pictures of the breast before combining them into a 3-D rendering. The images can also be taken apart and examined individually, thereby lessening the problem of overlapping tissue. The result is a more accurate view of the breast that allows the radiologist to better determine the size, shape, and location of an abnormality than standard mammography.
For the patient, the experience is similar to that of standard mammography, although, due to longer exposure time, the radiation dose is slightly higher than that of standard mammography. On the other hand, the accuracy of tomosynthesis has been shown to minimize the need for repeat images.17 Like digital mammography, this technology may benefit women with dense breast tissue. Tomosynthesis was approved by the FDA in 2011 for routine clinical use, although some insurance companies still consider this technology experimental.
Information for Every Woman Counts (EWC) Providers
The accuracy of tomosynthesis has not yet been compared with that of standard mammography in randomized trials. As a result, it is not yet known whether this type of imaging is better than standard mammography at avoiding false-positive results and identifying early breast cancer.15 NBCCEDP and EWC do not provide payment for tomosynthesis.
Magnetic Resonance Imaging (MRI)
The USPSTF has concluded that the current evidence is insufficient to assess the additional benefits and harms of MRI as a screening modality for breast cancer.13 However, ACS recommends its use in screening with certain high risk women.9 Specifically, for women whose lifetime risk is greater than 20%, ACS recommends an annual MRI in addition to mammography. Women with 15% to 20% lifetime risk are advised to talk with their healthcare providers about the benefits and risks of adding MRI to their annual screening mammogram. For women whose lifetime risk of breast cancer is less than 15%, ACS does not recommend MRI screening.18
. Source: Dr. Steven Harmes. Baylor Univ Medical Center, Dallas Texas. Adapted from NCI Visuals Online. AV-9402-4285.
Color-enhanced slide shows magnetic
resonance image (MRI) of individual breast.
MRI uses magnets and radio waves to produce
very detailed, cross-sectional images of the body.
MRI has been shown to detect more
cancers than mammography alone; however, false-positive results are also greater than mammography, leading to additional imaging and benign biopsies.
Other concerns with MRI are its inability to detect microcalcifications,
equipment variability, and a lack of standardized exam
techniques and interpretation criteria. It is also much more expensive than mammography (about 10 times
more) and availability remains limited.
Information for Every Woman Counts (EWC) Providers
Clinical breast examination (CBE) was long considered an important component of routine screening. Its purpose is to detect masses that may be missed with mammography, discover interval lesions that may appear between screenings, or evaluate a lump or skin/nipple change discovered by a woman.19
Most of the supporting evidence for CBE has been derived indirectly, from studies that include CBE in combination with mammography.20 We know of no studies that have compared CBE with that of no
screening and none that have examined CBE plus mammography versus mammography alone. As a result, the independent impact on mortality reduction remains unclear, leaving the USPSTF to conclude "that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older."13 Still, with reported sensitivity ranging between 40% to 69%, and a
specificity in the range of 88% to 99%,21 the Task Force has stated that the "evidence for CBE, although indirect, suggests that CBE may detect a substantial proportion of cases of cancer if it is the only screening test available."13As of 2015, The American Cancer Society no longer recommends CBE for average risk women of any age.9
Nevertheless, other guideline authors continue to recommend CBE, not only in the absence of mammography, but also as an adjunct to mammography for all age-appropriate women (e.g., American College of Obstetrics and Gynecology).22 While easy to learn, proper training of a structured, standardized CBE is essential for maximizing the benefit of this screening method with patients. In studies of CBE training with silicone breast models, findings have consistently demonstrated improved performance after training, as measured by the execution of various tactile skills and their contribution to detection accuracy.23
CBE is typically performed
at the yearly physical examination and preferably on days 6-10 of the menstrual cycle. A comprehensive
CBE includes a health history (review of any patient concerns or symptoms and risk factors);
visual inspection (for general contour, symmetry, color, texture, dimpling, retraction); lymph node examination (supra- and infraclavicular, and axillary nodes); patient positioning (modified supine position, hip and lower back supported, knees flexed in contralateral direction, ipsilateral shoulder rotated with back of hand on forehead); proper coverage and technique with regard to perimeter, pattern, palpation and pressure;
patient education (with emphasis on breast awareness, regular screening); and plan of action (screening intervals, or for women with abnormal CBE results, work-up plan).
Proper documentation of all findings is crucial.19
Clinical tools to assist providers with
CBE have been developed by the Cancer Detection Section, California Department
of Public Health. The following may be viewed or downloaded from this
Competencies of CBE (video) to supplement a comprehensive training. (The most effective training includes hands-on exam opportunities with feedback from a patient instructor and clinical faculty.)
This website also hosts the Breast
Cancer Diagnostic Algorithms for Primary Care Providers (4th ed.), a publication of the Cancer Detection Section, California Department of Public Health. Developed for primary care providers enrolled in Every Woman Counts (EWC), the algorithms are primarily intended for use with women aged 40 and older. The set of seven algorithms
provides detailed guidance for the work-up of a new
palpable mass; abnormal screening mammogram with
normal CBE; spontaneous unilateral nipple discharge;
breast skin changes (including nipple retraction); and breast pain. There is also
a risk assessment table, and in the case of breast
biopsy, an algorithm for the management of pathologic
Numerous professional organizations, including the US Preventive Services Task Force, American Academy of Family Physicians, and Canadian Task Force on Preventive Health Care, recommend against clinicians teaching women how to perform BSE, concluding that adequate evidence suggests that teaching BSE does not reduce breast cancer mortality. 24 The American College of Obstetricians and Gynecologists (ACOG) encourages all women to become familiar with how their breasts normally look and feel so that anything out of the ordinary can be promptly brought to the attention of their healthcare providers.
The most common signs
of possible breast cancer:
a new breast lump or mass
thickening in or near the breast or underarm area
a swelling of part of the breast
skin irritation, dimpling, or distortion
redness or scaling of the breast skin or nipple
nipple pain, inversion, rash or tenderness
nipple discharge other than breast milk
non-cyclical breast pain
Any change in the normal appearance or
texture of a woman's breast should be examined by a
healthcare professional. The most common signs of possible breast
cancer are a new breast lump or mass, or thickening
in or near the breast or underarm area. Other signs and symptoms include swelling of part of the breast; skin irritation,
dimpling, or distortion; redness or scaling of the
breast skin or nipple; nipple pain, inversion, rash
or tenderness; or nipple discharge other than breast
milk. Additionally, non-cyclical breast pain, which
may occur for many reasons
other than breast cancer, should always be brought
to the attention of a healthcare provider.
In addition to the benefits associated
with routine screening,
women should be informed about its limitations and
potential harms. As noted by the USPSTF, potential harms include "psychological harms, additional medical visits, imaging, and biopsies in women without cancer, inconvenience due to false-positive screening results, harms of unnecessary treatment, and radiation exposure."25 Specific issues for providers to discuss with
their patients are listed below:
False positives may require
follow-up testing or invasive procedures such as
breast biopsy to resolve the diagnosis. False positives
can cause anxiety, inconvenience, discomfort, and
additional medical expenses. Additional testing also
poses additional risks.
False negatives may provide
false reassurance and/or delayed diagnosis. For example,
a woman who receives a false negative test result
may delay seeking medical care even if she has symptoms.
Overtreatment may be
caused by screening mammograms that lead to medical
interventions for certain cases of ductal carcinoma
in situ (DCIS) that may never have become clinically apparent or needed treatment.
Since it is not currently possible to predict which
cases of DCIS will progress to invasive cancer, overtreatment
is a potential harm associated with screening.
Radiation exposure is
a risk factor for breast cancer. Overall risk from
single or cumulative diagnostic exposure from mammography
is very small. However, risk increases with the amount
of exposure and with exposure at younger ages.
of early detection is decreased morbidity and
mortality from breast cancer.
Despite these potential harms, most medical
experts agree that breast cancer screening in accordance
with recommended guidelines substantially increases
the chances of early detection, and the benefit of
early detection is decreased morbidity and mortality
from breast cancer. Moreover, the benefit increases
as women age. With regard to mammography, the USPSTF states that there is convincing evidence that this screening modality reduces breast cancer mortality, "with a greater absolute reduction for women aged 50 to 74 years than for women aged 40 to 49 years." It further concludes that the "strongest evidence for the greatest benefit is among women aged 60 to 69 years."8 Studies
conducted to date have not shown a benefit for regular
screening mammograms, or for a baseline screening mammogram,
in women under age 40.
and Emerging Methods
Research in the field of breast cancer
screening is focused on increasing both the sensitivity
and specificity of detection. Other methods currently
being evaluated for their screening potential include tissue sampling (e.g., fine needle aspiration, nipple aspiration, ductal lavage); scintimammography (molecular breast imaging); electrical impedance imaging (T-scan); thermography (thermal imaging);
positron emission mammography; and optical imaging (e.g., computed tomography laser mammography, optoacoustic tomography), among others.
and End Results (SEER). (2011, November 10). SEER stat fact sheets: breast cancer. Retrieved
Cancer Society. (2012, January 6). What
are the key statistics for breast cancer? Retrieved from: http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-key-statistics
Cancer Society. (2012). Breast cancer
facts & figures 2011-2012. Retrieved
Venkataraman, S., & Slanetz, P. (2012, December). Breast imaging: mammography and ultrasonography. Retrieved
from the Up to Date website: http://www.uptodate.com/contents/breast-imaging-mammography-and-ultrasonography
Women ages 50 and older are likely to receive a greater net benefit from regular screening mammography than women ages 40 to 49. An analysis performed for the U.S. Preventive Services Task Force found that "screening between the ages of 50 and 69 years produced a projected 17% (range, 15% to 23%) reduction in mortality (compared with no screening), whereas extending the age range produced only minor improvements (additional 3% reduction from starting at age 40 years and 7% from extending to age 79 years)." (See note 12.)
Barth, R. J., Jr, Gibson, G. R., Carney, P. A., Mott, L. A., Becher, R. D., & Poplack, S. P. (2005). Detection of breast cancer on screening mammography allows patients to be treated with less-toxic therapy. American Journal of Roentgenology, 184, 324-239. doi: 10.2214/ajr.184.1.01840324
Centers for Disease Control and Prevention. (n.d). National Breast and Cervical Cancer Early Detection Program (NBCCEDP): About the program. Retrieved from: http://www.cdc.gov/cancer/nbccedp/about.htm
National Guideline Clearinghouse. (n.d.) Guideline summary: (1) Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. (2) December 2009 addendum. Retrieved from: http://www.guideline.gov/content.aspx?id=15429
Oeffinger, K. C., Fontham, E. T. H., Etzioni, R., Herzig, A., Michaelson, J. S., Ya-Chen, T. S.,…Wender, R. (2015). Breast cancer screening update for women at average risk. 2015 guideline update from the American Cancer Society. JAMA, 314(15): 1599-614.doi: 10.1001/jama.2015.12783
The American College of Obstetricians and Gynecologists. (2011, August). Practice bulletin no. 122: breast cancer screening. Obstetrics & Gynecology, 118 (2 Pt 1): 372-82. doi: 10.1097/AOG.0b013e31822c98e5
Breast Cancer Surveillance Consortium (BCSC). (2012, August 9). Sensitivity and specificity for 2,264,089 screening mammography examinations from 2002 - 2006 - based on BCSC data as of 2009. Retrieved from: http://breastscreening.cancer.gov/data/benchmarks/screening/2009/tableSensSpec.html
American College of Radiology (ACR). BI-RADS® Atlas (excerpted text) - Mammography, fourth edition. Retrieved from: http://www.acr.org/Quality-Safety/Resources/BIRADS/Mammography
United States Preventive Services Task Force (USPSTF). (2009, November). Screening for breast cancer: U.S. preventive services task force recommendation statement. Retrieved from: http://www.annals.org/content/151/10/716.full.pdf+html
Science Daily. (2010, January 21). Digital mammography delivers significantly less radiation than conventional mammography. Retrieved from: http://www.sciencedaily.com/releases/2010/01/100121135704.htm
National Cancer Institute. (2012, July 24). Mammograms. Retrieved from: http://www.cancer.gov/cancertopics/factsheet/detection/mammograms
J., Abraham, L., Taplin, S. H., Geller, B. M., Carney, P. A., D'Orsi, C., ...Barlow, W. E., for the Breast Cancer Surveillance Consortium. (2011). Effectiveness of computer-aided detection in community mammography practice. Journal of the National Cancer Institute, 103, 1-10. doi: 10.1093/jnci/djr206
American Roentgen Ray Society (ARRS). (2012, May). Digital breast tomosynthesis cuts recall rates by 40 percent. Retrieved from the Eurekalert website: http://www.eurekalert.org/pub_releases/2012-05/arrs-dbt042312.php
Cancer Society. (2012, August 30). American Cancer Society recommendations for early cancer detection in women without breast symptoms. Retrieved from: http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs
Centers for Disease Control and Prevention (CDC). (2007, April). National Breast and Cervical Cancer Early Detection Program: screening and diagnostic services. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.
Fletcher, S. W. (2012, October 3). Screening for breast cancer. Retrieved from the Up to Date website: http://www.uptodate.com/contents/screening-for-breast-cancer
Humphrey, L. L., Helfand, M., Benjamin, K. S., Chan, M. S. & Woolf, S. H. (2002). Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 137, 344-346. doi: 10.7326/0003-4819-137-5_Part_1-200209030-00012
of breast cancer screening guidelines by major review
groups is available from National Guideline Clearinghouse
(NGC) at: http://guideline.gov
Saslow, D., Hannon, J., Osuch, J., Alciati, M. H., Baines, C., Barton, M.,...Coates, R. (2004). Clinical breast examination: practical recommendations for optimizing
performance and reporting. CA: A Cancer Journal for Clinicians, 45(6), 327-344.
Cancer Society. (2011, October 4). Breast awareness and self-exam. Retrieved from: http://www.cancer.org/Cancer/BreastCancer/MoreInformation/BreastCancerEarlyDetection/breast-cancer-early-detection-acs-recs-bse
United States Preventive Services Task Force (USPSTF). (2009, December). Screening for breast cancer: clinical summary of 2009 U.S. Preventive Services Task Force recommendation. Retrieved from: http://www.uspreventiveservicestaskforce.org/uspstf09/breastcancer/brcansum.htm
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