Breast Cancer Screening and Management

Lesion Characteristics and Risk

• Adenosis is a non-proliferative lesion that is part of benign breast changes, as stated by the American College of Radiology 1
• Women with atypical lobular hyperplasia (ALH) are considered intermediate-risk for breast cancer, with a lifetime breast cancer risk approximately 4-5 times that of the general population, according to the American College of Radiology (ACR) and American Cancer Society guidelines 2, 3, 1, 4
• Proliferative breast disease without atypia carries a modestly increased risk of breast cancer (approximately 1.5-1.9 times) compared to women with non-proliferative lesions, as reported by the ACR and NCCN guidelines 1
• Up to 30% of women with excision for proliferative lesions with atypia may develop breast cancer, according to the American College of Radiology 1

Screening Recommendations

• Annual mammography is strongly recommended for women with ALH, with no upper age limit established for screening mammography, and supported by the ACR and NCCN guidelines 2, 3
• Digital breast tomosynthesis (DBT) is preferred over standard mammography when available, especially beneficial for women with dense breasts, as recommended by the ACR and NCCN guidelines 2, 3
• Breast MRI should be considered as supplemental screening, particularly valuable for women with ALH who have dense breast tissue, additional risk factors, or limited financial resources, with a Category 1 recommendation (highest level of evidence) from the NCCN guidelines 5, 6
• The following table summarizes the benefits of different imaging modalities:

• Clinical breast examinations every 6-12 months and breast awareness should be encouraged, with consideration of supplemental screening with breast MRI, especially for women with dense breasts, according to the ACR and NCCN guidelines 7, 1, 6, 8

Management of ALH and LCIS

• Surgical excision is indicated for extensive ALH (>3-4 foci), associated with microcalcifications, or radiologic-pathologic discordance exists, according to the NCCN guidelines, with a Category 1 recommendation (highest level of evidence) 9, 8, 10
• Minimal ALH (≤3 foci) with radiologic concordance may not require excision, as per the NCCN recommendations, with a Category 2A recommendation (high level of evidence) 9, 8
• Chemoprevention is recommended for all patients with ALH or LCIS, with tamoxifen reducing invasive breast cancer risk by approximately 46% in premenopausal women, and a Category 1 recommendation (highest level of evidence) from the NCCN guidelines 9, 11, 6
• The following table summarizes the management of ALH and LCIS:

Special Considerations

• Prioritize annual mammography as the essential screening modality for patients without health insurance, with exploration of local resources for low-cost or free mammography, such as the CDC's National Breast and Cervical Cancer Early Detection Program, as recommended by the NCCN guidelines 12
• Consider MRI only if financial assistance is available, as it provides significant additional benefit but at higher cost, according to the ACR and NCCN guidelines 5, 6
• Breast density and other risk factors should be considered when determining appropriate screening for patients with proliferative breast disease without atypia, with referral to ACR guidelines on "Supplemental Breast Cancer Screening Based on Breast Density" for women with dense breasts, as recommended by the ACR and NCCN guidelines 1, 2
• Annual mammography has been shown to reduce breast cancer mortality by at least 22% in randomized controlled trials, as reported by the ACR and NCCN guidelines 3