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Breast Cancer Screening

Measure Description
NameDescriptionNumeratorDenominatorSourceReference
Breast Cancer ScreeningPercentage of women 40 to 69 years of age who had a mammogramWomen in the denominator who received one or more mammograms during the measurement year or the year prior to the measurement yearAll women patients aged 42 to 69 years of age during the measurement year or year prior to the measurement yearNCQA / NQFNational Committee for Quality Assurance Exit Disclaimer.

Part 1: Introduction

Part 2: Characteristics for Success: Breast Cancer Screening

Part 3: Implementation of Quality Measure: Breast Cancer Screening

Part 4: Improvement Strategies: Breast Cancer Screening

Part 5: Holding the Gains and Spreading Improvement

Part 6: Supporting Information


Part 1: Introduction 

Breast cancer is the most common female cancer in the United States for every major ethnic group and the second most common cause of cancer death in women. Annually, approximately 182,460 American women are diagnosed with breast cancer, and 40,480 die from the disease. (1) The lifetime probability of developing breast cancer is one in six overall (one in eight for invasive disease) (2). Even if breast cancer incidence cannot be substantially reduced for some women who are at high risk for developing the disease, the risk of death from breast cancer can be reduced by regular mammography screening. Breast cancer screening improves earlier discovery of the disease while it is more treatable and has not spread.

There are interracial differences (3) in breast cancer incidence as shown in Figure 1.1: Rates of Female Breast Cancer. As an example, data from the American Cancer Society (ACS) indicates that the highest rates occur in Whites (133 cases per 100,000 women). The rates are lower in Blacks (118 per 100,000), Asian Americans/Pacific Islanders (89 per 100,000), Hispanic/Latina women (89 per 100,000), and American Indians/Alaska Natives (70 per 100,000) (4) 

Figure 1.1: Rates of Female Breast Cancer.
Figure 1.1: Rates of Female Breast Cancer

Much of these ethnic differences are attributable to factors associated with lifestyle and socioeconomic status, for example, access to screening and treatment services, which may explain some of the disparities in survival that are attributed solely to race. Genetic and biologic factors also may contribute. (5) As an example, two observations have been noted in Black women. First, Black women have an earlier age peak than White women. (6) Secondly, Black women have higher mortality rates from breast cancer than White women despite the lower incidence overall. This is due to a more advanced stage at diagnosis plus a higher stage-specific mortality. Some data suggests that Black women have more aggressive cancers (e.g., hormone receptor-negative) associated with a higher mortality rate. (7)

The mortality rate from breast cancer has been decreasing since 1990. Some of the decline in mortality may be due to screening. Using seven different statistical models, estimates of the total reduction proportion in overall U.S. breast cancer mortality that was attributable to mammogram screening ranged from 28 to 65 percent (median 46 percent), with adjuvant treatment accounting for the rest. These results suggest breast cancer mortality in the United States has dropped about 10 percent because of screening. (8)

Breast cancer mortality rates in Black women in the United States declined somewhat less. Black women may have their breast cancer diagnosed at a later stage due to lower use of mammography. A study of over one million women who had at least one mammogram between 1996 and 2002 found that Black women were more likely to have inadequate mammographic screening than White women (RR 1.2, 95% CI 1.2-1.2). (9) This discrepancy was even more striking among women diagnosed with breast cancer (RR 1.6, 1.5-1.8). Black women were more likely to have large, advanced-stage, high-grade, and lymph-node positive breast tumors. Differences in size, stage, and lymph-node positivity (though not grade) were no longer significant when Black and White women with the same screening history were compared.

Women of higher socioeconomic status are at greater risk for breast cancer—up to a twofold increase in incidence from lowest to the highest strata. There are also significant variations in the prevalence of breast cancer regionally in the United States. (10) The influence of socioeconomic status (educational, occupational, and economic level) and regional norms is thought to reflect differing reproductive patterns with respect to parity, age at first birth, age at menarche, and use of screening mammography.

Current and evolving clinical issues include determining who should be screened (risk stratification, age to begin screening, age to stop) and what method should be used for screening. There is a strong consensus that routine screening mammography should be offered to women aged 50 to 69 years. There is less agreement about the following components of breast cancer screening: routine mammography screening for women aged 40 to 49 or over 70, the frequency of mammography screening, and the role of exams, such as, clinical breast exam and breast self-examination. Shared decision making with patients becomes particularly important when addressing these areas where the evidence is less clear. Absolute mortality benefit for women screened annually starting at age 40 years is 4 per 10,000 at 10.7 years. (11) The comparable number for women screened annually starting at age 50 years is approximately 5 per 1,000. Absolute benefit is approximately one percent overall but depends on inherent breast cancer risk, which rises with age.

Mammography remains the mainstay of screening for breast cancer and is able to detect cancers before they are palpable. (12) Film and digital mammography are equally efficacious for screening overall. Digital techniques may be preferred for premenopausal women, those with dense breasts, and those with significant fears about radiation exposure, but they are significantly more expensive than film techniques. (13) Other imaging techniques play an important role in additional diagnostic evaluations for women with positive screening tests. UItrasonography is commonly used for diagnostic follow-up of an abnormality seen on screening mammography and to clarify features of a potential lesion. The role of magnetic resonance imaging (MRI) for breast cancer screening is emerging; MRI screening, in combination with mammography, is currently targeted at high-risk patients. Newer tests, such as tomography, are under evaluation.(14) Imaging studies cannot establish a diagnosis of cancer. Rather, they identify patients with abnormal findings who must then be further evaluated with follow-up imaging or a biopsy. The diagnosis of cancer is dependent on obtaining a tissue sample.

Other screening strategies, including clinical breast exam (CBE) and breast self exam (BSE), are significantly less sensitive to detect breast cancers, but they continue to be used in conjunction with mammography. The National Breast and Cervical Cancer Early Detection Program, (15) which studied the value of CBE in the community setting where procedural guidelines for performing the examination were not dictated, found CBE still detected about five percent of cancers that were not visible on mammography. Breast self examination has not demonstrated significant additional benefit to mammographic screening although there is some evidence that cancers may be detected earlier.(16)

Although the challenge is daunting, it is clear that experts do know how to screen for breast cancer and are continually increasing public knowledge about screening recommendations. The scientific literature, centers of excellence in breast cancer screening, and the experience of health care organizations are consistent in pointing to common themes in effective breast cancer screening programs.

Performance Measurement: Breast Cancer Screening

Measuring performance allows an organization to document how care is currently provided and sets the foundation for improvement. The Breast Cancer Screening clinical quality measures designed to measure the percentage of patients aged 40 to 69 years who have been screened for breast cancer with mammography during the measurement year or year prior to the measurement year. This measure is intended to ensure appropriate screening for those women of average risk for breast cancer. The goal is to further reduce the morbidity and mortality associated with breast cancer by ensuring that patients access mammography, a highly effective screening test for breast cancer, at least biennially.

Higher risk women are those with a prior history of breast cancer, certain familial syndromes, and specific genetic markers. These women may require screening at an earlier age, additional imaging techniques, and screening at more frequent intervals. Further discussion about this evolving topic is beyond the scope of this module, but additional information can be obtained in the medical literature, including these resources: (17, 18)

Measuring performance on this clinical quality measure encourages an organization to improve systems so that all women of appropriate age have access to regular and ongoing screening for breast cancer. The performance measurement for this clinical quality measure focuses on systems for Breast Cancer Screening for women of average risk, but work to improve performance on this measure will likely improve Breast Cancer Screening for all women.

Consider the characteristics of an effective performance measure and the Institute of Medicine (IOM) framework, Envisioning the National Healthcare Quality Report Exit Disclaimer.:

  • Relevance: Does the performance measure relate to a frequently-occurring condition or have an impact on patients at an organization's facility?
  • Measurability: Can the performance measure realistically and efficiently be quantified given the facility's finite resources?
  • Accuracy: Is the performance measure based on accepted guidelines or developed through formal group decision-making methods?
  • Feasibility: Can the performance rate associated with the performance measure realistically be improved given the limitations of the clinical services and patient population?

To ensure that a performance measure has these characteristics, it is often based on, or aligned with, current evidence-based guidelines and proven measures.

The Breast Cancer Screening measure aligns with measures endorsed by the National Committee for Quality Assurance (NCQA) and similar performance metrics used by HRSA grantees and programs. Similar measures also exist in the national measure set for Healthy People 2020.

Clinical Quality Measure: Breast Cancer Screening 

NameDescriptionNumeratorDenominatorSourceReference
Breast Cancer ScreeningPercentage of women 40 to 69 years of age who had a mammogramWomen in the denominator who received one or more mammograms during the measurement year or the year prior to the measurement yearAll women patients aged 42 to 69 years of age during the measurement year or year prior to the measurement yearNCQA / NQFNational Committee for Quality Assurance Exit Disclaimer.

As with all performance measures, there are essential inclusions, exclusions, and clarifications required to ensure an organization collects and reports data in the same way. This allows an organization using the measure to compare itself with others. Detailed specifications for the measure, with descriptions of inclusion and exclusion criteria, are found in the section, Part 3: Data Infrastructure: Breast Cancer Screening.

Practical Considerations

Health care professionals should be familiar with several key topics to appropriately screen women for breast cancer. Advanced discussion is beyond the scope of this module, but the reader is encouraged to review other resources for further information, including those listed here.

Risk Factors Associated with Breast Cancer

Patients commonly ask health care professionals about risks associated with breast cancer and what can be done to prevent it. Current evidence about risk factors and breast cancer is summarized in Figure 1.2: Risk and Protective Factors. These risks can be used to guide screening but are not intended to predict individual risk. An organization should leverage opportunities to discuss the following modifiable risk factors to minimize breast cancer risks with women, in addition to recommending screening mammography:

  • Minimize the duration of postmenopausal hormones; consider non-estrogenic alternatives (e.g., bisphosphonates for treatment of osteoporosis).
  • Have the first child at an earlier age.
  • Breastfeed for at least six months.
  • Avoid adult weight gain and maintain a healthy weight to reduce postmenopausal breast cancer risk; however, it has not been fully demonstrated that a specific diet, food group, or vitamin supplements reduce risk.
  • Limit alcohol consumption.
  • Maintain regular physical exercise.

Understanding Benefits and Harms of Screening

The benefits of screening have been delineated throughout this module. Screening recommendations carefully balance the benefits and harms associated with various screening techniques. Mammography is clearly beneficial to detect cancer before symptoms are evident, but is not without harms. With the advent of readily accessible information, harms may be presented to patients in a manner that is frightening and out of context. Understanding the potential harms, such as, false positive screenings, radiation exposure, and discomfort, allows a frank dialogue of risks and benefits that are patient centered. A detailed discussion is beyond the scope of this module, but an organization may find this resource helpful to understand the benefits and harms of mammography screening.

Figure 1.2: Risk and Protective Factors for Developing Breast Cancer  

Type of FactorsRisk Group
Risk FactorsLow RiskHigh RiskRelative Risk
Deleterious BRCA1/BRCA2 genesNegativePositive3.0 - 7.0
Mother or sister with breast cancerNoyes2.5
Age30 -34>70 - 7418.0
Age at menarche>14<121.5
Age at first birth<20>301.9 - 2.5
Age at menopause<45>552.0
Use of contraceptive pillsNeverPast/current use1.07 to 1.2
HRT (estrogen + progestin)NeverCurrent1.2
AlcoholNone2 to 5 drinks/day1.4
Breast density on mammography (percents)0>751.8 to 6.0
Bone DensityLowest quartileHighest quartile2.7 to 3.5
History of a benign breast biopsyNoYes1.7
History of atypical hyperplasia on biopsyNoYes3.7
Protective Factors
Breast Feeding (months)>1600.73
Parity>500.71
Recreational exerciseYesNo0.75
Post menopause body mass index (kg/m2)<22.9>30.70.63
Oophorectomy before age 35 yearsYesNo0.3
Aspirin>Once/week for >6 monthsNonusers0.79
Adapted from Clemons, M, Goss, P. Estrogen and the risk of breast cancer. N Engl J Med 2001; 344:276."


The Importance of Shared Decision Making 

Most national authorities agree that women should begin mammography screening by age 50. The consensus is lower for screening those aged 40 to 50 years. From an overall population perspective, the risks are greater than the benefits, but an organization is encouraged to consider individual patient risks and benefits when making its screening recommendations. At the time of this writing, the American Cancer Society, (19) American College of Radiology, (20) American Medical Association, (21) National Cancer Institute, (22) American College of Obstetrics and Gynecology, (23) and the National Comprehensive Cancer Network (NCCN) (24) recommend starting routine screening at age 40 years. The American Academy of Family Physicians (25) recommends screening mammography every one to two years for women ages 40 and older. After a careful review of data in 2009, the United States Preventive Services (26) Task Force (USPSTF) updated its previous recommendation to begin routine screening at age 50 years.

There is also remaining controversy about annual versus biennial mammography screening. There is a consensus that mammography screening intervals should not exceed two years.

It is important for an organization to discuss patients' individual risks, their fears of diagnosis and harm from the screening, cultural influences, previous experiences, values, and perceived barriers to screening that might impact individual decisions. Salient highlights of the discussion and decision reached should be documented in the medical record for all female patients aged 40 years and older.

Improvement Experience: Breast Cancer Screening

The importance of Breast Cancer Screening as part of comprehensive preventive care for women is widely accepted. Systematic approaches are necessary to achieve improvements in the quality of care delivery and reliable screening for patients. Improvements in mammography rates since the 1990s have been attributed to increased insurance coverage for this test, subsidized mammography services for low-income women, and educational outreach to providers and the public. (27) As shown in Figure 1.3: Number of Women Receiving Mammograms between 1991 and 2002, the CDC-sponsored National Breast and Cervical Cancer Early Detection Program (NBCCEDP) demonstrated that outreach, community partnerships, and financial subsidy of the cost of testing improved mammogram screening rates during that time period.

Figure 1.3: Number of Women Receiving Mammograms between 1991 and 2002.
Figure 1.3: Number of Women Receiving Mammograms between 1991 and 2002

HRSA-sponsored programs, including Federally Qualified Health Centers, demonstrated improvement in screening rates, which increased from 62.5 percent in 1995 to 75.7 percent in 2002, as evidenced by the 2002 Health Center User Program. (28) Beginning in 2002, HRSA sponsored targeted improvement efforts to increase screening rates for breast, colon, and cervical cancer. Following tested improvement methodologies, health care teams were able to make statistically-significant improvements in the breast cancer screening rates. Improvement strategies and results are outlined in the resource that can be found here.

In 2009, NCQA data revealed continued improvement of mammography screening rates from 2008. The following rates indicate there has been improvement, but more work needs to be done:

  • Commercial - 70.2 percent
  • Medicare - 68 percent
  • Medicaid - 50.8 percent

Putting systems in place to track performance enable an organization to better understand how effectively it is able to screen a population of patients for breast cancer. Women of this age range often comprise a large percentage of the total number of patients in a practice, so systems must be robust to track interval care for large numbers of individuals. These same tracking systems can facilitate appropriate management and follow-up for patients with positive screening tests and provide critical steps to connect patients with prompt appropriate care.




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