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Supplemental Breast Cancer Screening Based on Breast Density
Variant: 1
Adult female. Supplemental breast cancer screening. Average risk. Nondense breasts.
| Procedure | Appropriateness Category | Relative Radiation Level |
| Digital breast tomosynthesis screening | Usually Appropriate | ☢☢ |
| US breast | Usually Not Appropriate | O |
| Mammography with IV contrast | Usually Not Appropriate | ☢☢ |
| MRI breast without and with IV contrast | Usually Not Appropriate | O |
| MRI breast without and with IV contrast abbreviated | Usually Not Appropriate | O |
| MRI breast without IV contrast | Usually Not Appropriate | O |
| MRI breast without IV contrast abbreviated | Usually Not Appropriate | O |
| FDG-PET breast dedicated | Usually Not Appropriate | ☢☢☢ |
| Sestamibi MBI | Usually Not Appropriate | ☢☢☢ |
Variant: 2
Adult female. Supplemental breast cancer screening. Average risk. Heterogeneously dense breasts.
| Procedure | Appropriateness Category | Relative Radiation Level |
| Digital breast tomosynthesis screening | Usually Appropriate | ☢☢ |
| US breast | May Be Appropriate | O |
| MRI breast without and with IV contrast | May Be Appropriate | O |
| MRI breast without and with IV contrast abbreviated | May Be Appropriate | O |
| Mammography with IV contrast | Usually Not Appropriate | ☢☢ |
| MRI breast without IV contrast | Usually Not Appropriate | O |
| MRI breast without IV contrast abbreviated | Usually Not Appropriate | O |
| FDG-PET breast dedicated | Usually Not Appropriate | ☢☢☢ |
| Sestamibi MBI | Usually Not Appropriate | ☢☢☢ |
Variant: 3
Adult female. Supplemental breast cancer screening. Average risk. Extremely dense breasts.
| Procedure | Appropriateness Category | Relative Radiation Level |
| Digital breast tomosynthesis screening | Usually Appropriate | ☢☢ |
| MRI breast without and with IV contrast | Usually Appropriate | O |
| MRI breast without and with IV contrast abbreviated | Usually Appropriate | O |
| US breast | May Be Appropriate | O |
| Mammography with IV contrast | Usually Not Appropriate | ☢☢ |
| MRI breast without IV contrast | Usually Not Appropriate | O |
| MRI breast without IV contrast abbreviated | Usually Not Appropriate | O |
| FDG-PET breast dedicated | Usually Not Appropriate | ☢☢☢ |
| Sestamibi MBI | Usually Not Appropriate | ☢☢☢ |
Variant: 4
Adult female. Supplemental breast cancer screening. Intermediate risk. Nondense breasts.
| Procedure | Appropriateness Category | Relative Radiation Level |
| Digital breast tomosynthesis screening | Usually Appropriate | ☢☢ |
| MRI breast without and with IV contrast | May Be Appropriate (Disagreement) | O |
| MRI breast without and with IV contrast abbreviated | May Be Appropriate | O |
| US breast | Usually Not Appropriate | O |
| Mammography with IV contrast | Usually Not Appropriate | ☢☢ |
| MRI breast without IV contrast | Usually Not Appropriate | O |
| MRI breast without IV contrast abbreviated | Usually Not Appropriate | O |
| FDG-PET breast dedicated | Usually Not Appropriate | ☢☢☢ |
| Sestamibi MBI | Usually Not Appropriate | ☢☢☢ |
Variant: 5
Adult female. Supplemental breast cancer screening. Intermediate risk. Heterogeneously dense breasts.
| Procedure | Appropriateness Category | Relative Radiation Level |
| Digital breast tomosynthesis screening | Usually Appropriate | ☢☢ |
| MRI breast without and with IV contrast | Usually Appropriate | O |
| MRI breast without and with IV contrast abbreviated | Usually Appropriate | O |
| US breast | May Be Appropriate | O |
| Mammography with IV contrast | May Be Appropriate | ☢☢ |
| MRI breast without IV contrast | Usually Not Appropriate | O |
| MRI breast without IV contrast abbreviated | Usually Not Appropriate | O |
| FDG-PET breast dedicated | Usually Not Appropriate | ☢☢☢ |
| Sestamibi MBI | Usually Not Appropriate | ☢☢☢ |
Variant: 6
Adult female. Supplemental breast cancer screening. Intermediate risk. Extremely dense breasts.
| Procedure | Appropriateness Category | Relative Radiation Level |
| Digital breast tomosynthesis screening | Usually Appropriate | ☢☢ |
| MRI breast without and with IV contrast | Usually Appropriate | O |
| MRI breast without and with IV contrast abbreviated | Usually Appropriate | O |
| US breast | May Be Appropriate | O |
| Mammography with IV contrast | May Be Appropriate | ☢☢ |
| MRI breast without IV contrast | Usually Not Appropriate | O |
| MRI breast without IV contrast abbreviated | Usually Not Appropriate | O |
| FDG-PET breast dedicated | Usually Not Appropriate | ☢☢☢ |
| Sestamibi MBI | Usually Not Appropriate | ☢☢☢ |
Variant: 7
Adult female. Supplemental breast cancer screening. High risk. Nondense or dense breasts.
| Procedure | Appropriateness Category | Relative Radiation Level |
| Digital breast tomosynthesis screening | Usually Appropriate | ☢☢ |
| MRI breast without and with IV contrast | Usually Appropriate | O |
| MRI breast without and with IV contrast abbreviated | Usually Appropriate | O |
| US breast | May Be Appropriate | O |
| Mammography with IV contrast | May Be Appropriate | ☢☢ |
| MRI breast without IV contrast | Usually Not Appropriate | O |
| MRI breast without IV contrast abbreviated | Usually Not Appropriate | O |
| FDG-PET breast dedicated | Usually Not Appropriate | ☢☢☢ |
| Sestamibi MBI | Usually Not Appropriate | ☢☢☢ |
Panel Members
Susan P. Weinstein, a.
Summary of Literature Review
Introduction/Background
Discussion of Procedures by Variant
Variant 1: Adult female. Supplemental breast cancer screening. Average risk. Nondense breasts.
Variant 1: Adult female. Supplemental breast cancer screening. Average risk. Nondense breasts.
A. Digital breast tomosynthesis screening
A. Digital breast tomosynthesis screening
Variant 1: Adult female. Supplemental breast cancer screening. Average risk. Nondense breasts.
B. FDG-PET breast dedicated
B. FDG-PET breast dedicated
Variant 1: Adult female. Supplemental breast cancer screening. Average risk. Nondense breasts.
C. Mammography with IV contrast
C. Mammography with IV contrast
Variant 1: Adult female. Supplemental breast cancer screening. Average risk. Nondense breasts.
D. MRI breast without and with IV contrast
D. MRI breast without and with IV contrast
Variant 1: Adult female. Supplemental breast cancer screening. Average risk. Nondense breasts.
E. MRI breast without and with IV contrast abbreviated
E. MRI breast without and with IV contrast abbreviated
Variant 1: Adult female. Supplemental breast cancer screening. Average risk. Nondense breasts.
F. MRI breast without IV contrast
F. MRI breast without IV contrast
Variant 1: Adult female. Supplemental breast cancer screening. Average risk. Nondense breasts.
G. MRI breast without IV contrast abbreviated
G. MRI breast without IV contrast abbreviated
Variant 1: Adult female. Supplemental breast cancer screening. Average risk. Nondense breasts.
H. Sestamibi MBI
H. Sestamibi MBI
Variant 1: Adult female. Supplemental breast cancer screening. Average risk. Nondense breasts.
I. US breast
I. US breast
Variant 2: Adult female. Supplemental breast cancer screening. Average risk. Heterogeneously dense breasts.
Variant 2: Adult female. Supplemental breast cancer screening. Average risk. Heterogeneously dense breasts.
A. Digital breast tomosynthesis screening
A. Digital breast tomosynthesis screening
Variant 2: Adult female. Supplemental breast cancer screening. Average risk. Heterogeneously dense breasts.
B. FDG-PET breast dedicated
B. FDG-PET breast dedicated
Variant 2: Adult female. Supplemental breast cancer screening. Average risk. Heterogeneously dense breasts.
C. Mammography with IV contrast
C. Mammography with IV contrast
Variant 2: Adult female. Supplemental breast cancer screening. Average risk. Heterogeneously dense breasts.
D. MRI breast without and with IV contrast
D. MRI breast without and with IV contrast
Variant 2: Adult female. Supplemental breast cancer screening. Average risk. Heterogeneously dense breasts.
E. MRI breast without and with IV contrast abbreviated
E. MRI breast without and with IV contrast abbreviated
Variant 2: Adult female. Supplemental breast cancer screening. Average risk. Heterogeneously dense breasts.
F. MRI breast without IV contrast
F. MRI breast without IV contrast
Variant 2: Adult female. Supplemental breast cancer screening. Average risk. Heterogeneously dense breasts.
G. MRI breast without IV contrast abbreviated
G. MRI breast without IV contrast abbreviated
Variant 2: Adult female. Supplemental breast cancer screening. Average risk. Heterogeneously dense breasts.
H. Sestamibi MBI
H. Sestamibi MBI
Variant 2: Adult female. Supplemental breast cancer screening. Average risk. Heterogeneously dense breasts.
I. US breast
I. US breast
Variant 3: Adult female. Supplemental breast cancer screening. Average risk. Extremely dense breasts.
Variant 3: Adult female. Supplemental breast cancer screening. Average risk. Extremely dense breasts.
A. Digital breast tomosynthesis screening
A. Digital breast tomosynthesis screening
Variant 3: Adult female. Supplemental breast cancer screening. Average risk. Extremely dense breasts.
B. FDG-PET breast dedicated
B. FDG-PET breast dedicated
Variant 3: Adult female. Supplemental breast cancer screening. Average risk. Extremely dense breasts.
C. Mammography with IV contrast
C. Mammography with IV contrast
Variant 3: Adult female. Supplemental breast cancer screening. Average risk. Extremely dense breasts.
D. MRI breast without and with IV contrast
D. MRI breast without and with IV contrast
Variant 3: Adult female. Supplemental breast cancer screening. Average risk. Extremely dense breasts.
E. MRI breast without and with IV contrast abbreviated
E. MRI breast without and with IV contrast abbreviated
Variant 3: Adult female. Supplemental breast cancer screening. Average risk. Extremely dense breasts.
F. MRI breast without IV contrast
F. MRI breast without IV contrast
Variant 3: Adult female. Supplemental breast cancer screening. Average risk. Extremely dense breasts.
G. MRI breast without IV contrast abbreviated
G. MRI breast without IV contrast abbreviated
Variant 3: Adult female. Supplemental breast cancer screening. Average risk. Extremely dense breasts.
H. Sestamibi MBI
H. Sestamibi MBI
Variant 3: Adult female. Supplemental breast cancer screening. Average risk. Extremely dense breasts.
I. US breast
I. US breast
Variant 4: Adult female. Supplemental breast cancer screening. Intermediate risk. Nondense breasts.
Variant 4: Adult female. Supplemental breast cancer screening. Intermediate risk. Nondense breasts.
A. Digital breast tomosynthesis screening
A. Digital breast tomosynthesis screening
Variant 4: Adult female. Supplemental breast cancer screening. Intermediate risk. Nondense breasts.
B. FDG-PET breast dedicated
B. FDG-PET breast dedicated
Variant 4: Adult female. Supplemental breast cancer screening. Intermediate risk. Nondense breasts.
C. Mammography with IV contrast
C. Mammography with IV contrast
Variant 4: Adult female. Supplemental breast cancer screening. Intermediate risk. Nondense breasts.
D. MRI breast without and with IV contrast
D. MRI breast without and with IV contrast
Variant 4: Adult female. Supplemental breast cancer screening. Intermediate risk. Nondense breasts.
E. MRI breast without and with IV contrast abbreviated
E. MRI breast without and with IV contrast abbreviated
Variant 4: Adult female. Supplemental breast cancer screening. Intermediate risk. Nondense breasts.
F. MRI breast without IV contrast
F. MRI breast without IV contrast
Variant 4: Adult female. Supplemental breast cancer screening. Intermediate risk. Nondense breasts.
G. MRI breast without IV contrast abbreviated
G. MRI breast without IV contrast abbreviated
Variant 4: Adult female. Supplemental breast cancer screening. Intermediate risk. Nondense breasts.
H. Sestamibi MBI
H. Sestamibi MBI
Variant 4: Adult female. Supplemental breast cancer screening. Intermediate risk. Nondense breasts.
I. US breast
I. US breast
Variant 5: Adult female. Supplemental breast cancer screening. Intermediate risk. Heterogeneously dense breasts.
Variant 5: Adult female. Supplemental breast cancer screening. Intermediate risk. Heterogeneously dense breasts.
A. Digital breast tomosynthesis screening
A. Digital breast tomosynthesis screening
Variant 5: Adult female. Supplemental breast cancer screening. Intermediate risk. Heterogeneously dense breasts.
B. FDG-PET breast dedicated
B. FDG-PET breast dedicated
Variant 5: Adult female. Supplemental breast cancer screening. Intermediate risk. Heterogeneously dense breasts.
C. Mammography with IV contrast
C. Mammography with IV contrast
Variant 5: Adult female. Supplemental breast cancer screening. Intermediate risk. Heterogeneously dense breasts.
D. MRI breast without and with IV contrast
D. MRI breast without and with IV contrast
Variant 5: Adult female. Supplemental breast cancer screening. Intermediate risk. Heterogeneously dense breasts.
E. MRI breast without and with IV contrast abbreviated
E. MRI breast without and with IV contrast abbreviated
Variant 5: Adult female. Supplemental breast cancer screening. Intermediate risk. Heterogeneously dense breasts.
F. MRI breast without IV contrast
F. MRI breast without IV contrast
Variant 5: Adult female. Supplemental breast cancer screening. Intermediate risk. Heterogeneously dense breasts.
G. MRI breast without IV contrast abbreviated
G. MRI breast without IV contrast abbreviated
Variant 5: Adult female. Supplemental breast cancer screening. Intermediate risk. Heterogeneously dense breasts.
H. Sestamibi MBI
H. Sestamibi MBI
Variant 5: Adult female. Supplemental breast cancer screening. Intermediate risk. Heterogeneously dense breasts.
I. US breast
I. US breast
Variant 6: Adult female. Supplemental breast cancer screening. Intermediate risk. Extremely dense breasts.
Variant 6: Adult female. Supplemental breast cancer screening. Intermediate risk. Extremely dense breasts.
A. Digital breast tomosynthesis screening
A. Digital breast tomosynthesis screening
Variant 6: Adult female. Supplemental breast cancer screening. Intermediate risk. Extremely dense breasts.
B. FDG-PET breast dedicated
B. FDG-PET breast dedicated
Variant 6: Adult female. Supplemental breast cancer screening. Intermediate risk. Extremely dense breasts.
C. Mammography with IV contrast
C. Mammography with IV contrast
Variant 6: Adult female. Supplemental breast cancer screening. Intermediate risk. Extremely dense breasts.
D. MRI breast without and with IV contrast
D. MRI breast without and with IV contrast
Variant 6: Adult female. Supplemental breast cancer screening. Intermediate risk. Extremely dense breasts.
E. MRI breast without and with IV contrast abbreviated
E. MRI breast without and with IV contrast abbreviated
Variant 6: Adult female. Supplemental breast cancer screening. Intermediate risk. Extremely dense breasts.
F. MRI breast without IV contrast
F. MRI breast without IV contrast
Variant 6: Adult female. Supplemental breast cancer screening. Intermediate risk. Extremely dense breasts.
G. MRI breast without IV contrast abbreviated
G. MRI breast without IV contrast abbreviated
Variant 6: Adult female. Supplemental breast cancer screening. Intermediate risk. Extremely dense breasts.
H. Sestamibi MBI
H. Sestamibi MBI
Variant 6: Adult female. Supplemental breast cancer screening. Intermediate risk. Extremely dense breasts.
I. US breast
I. US breast
Variant 7: Adult female. Supplemental breast cancer screening. High risk. Nondense or dense breasts.
Variant 7: Adult female. Supplemental breast cancer screening. High risk. Nondense or dense breasts.
A. Digital breast tomosynthesis screening
A. Digital breast tomosynthesis screening
Variant 7: Adult female. Supplemental breast cancer screening. High risk. Nondense or dense breasts.
B. FDG-PET breast dedicated
B. FDG-PET breast dedicated
Variant 7: Adult female. Supplemental breast cancer screening. High risk. Nondense or dense breasts.
C. Mammography with IV contrast
C. Mammography with IV contrast
Variant 7: Adult female. Supplemental breast cancer screening. High risk. Nondense or dense breasts.
D. MRI breast without and with IV contrast
D. MRI breast without and with IV contrast
Variant 7: Adult female. Supplemental breast cancer screening. High risk. Nondense or dense breasts.
E. MRI breast without and with IV contrast abbreviated
E. MRI breast without and with IV contrast abbreviated
Variant 7: Adult female. Supplemental breast cancer screening. High risk. Nondense or dense breasts.
F. MRI breast without IV contrast
F. MRI breast without IV contrast
Variant 7: Adult female. Supplemental breast cancer screening. High risk. Nondense or dense breasts.
G. MRI breast without IV contrast abbreviated
G. MRI breast without IV contrast abbreviated
Variant 7: Adult female. Supplemental breast cancer screening. High risk. Nondense or dense breasts.
H. Sestamibi MBI
H. Sestamibi MBI
Variant 7: Adult female. Supplemental breast cancer screening. High risk. Nondense or dense breasts.
I. US breast
I. US breast
Summary of Highlights
Supporting Documents
The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.
For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.
Gender Equality and Inclusivity Clause
The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.
Appropriateness Category Names and Definitions
|
Appropriateness Category Name |
Appropriateness Rating |
Appropriateness Category Definition |
|
Usually Appropriate |
7, 8, or 9 |
The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients. |
|
May Be Appropriate |
4, 5, or 6 |
The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal. |
|
May Be Appropriate (Disagreement) |
5 |
The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned. |
|
Usually Not Appropriate |
1, 2, or 3 |
The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable. |
Relative Radiation Level Information
Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.
|
Relative Radiation Level Designations |
||
|
Relative Radiation Level* |
Adult Effective Dose Estimate Range |
Pediatric Effective Dose Estimate Range |
|
O |
0 mSv |
0 mSv |
|
☢ |
<0.1 mSv |
<0.03 mSv |
|
☢☢ |
0.1-1 mSv |
0.03-0.3 mSv |
|
☢☢☢ |
1-10 mSv |
0.3-3 mSv |
|
☢☢☢☢ |
10-30 mSv |
3-10 mSv |
|
☢☢☢☢☢ |
30-100 mSv |
10-30 mSv |
|
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.” |
||
References
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Disclaimer
The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment.
Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.