Breast cancer screening is typically accomplished in the United States by means of mammography. Film-based mammography has rapidly been replaced by digital mammography in the past decade, which will likely become the industry standard in the near future. Interpretation of mammograms is based on the BI-RAD system (Breast Imaging Reporting and Database), a numeric (0–6) scale for predicting the risk of malignancy from the mammographic appearance. Additional imaging techniques that may be used for screening in selected individuals include ultrasound, magnetic resonance imaging (MRI), and CT (computed tomography) scans. Ultrasound can be helpful in the evaluation of very dense breasts, particularly in young women. MRI can be more sensitive than mammography in some cases, but may miss certain cancers that mammography does not. MRI is therefore used primarily in combination with mammography, usually in women at higher risk for breast cancer based on family history or other factors. CT scans are rarely used in screening. Women with very large breasts and/or very large masses may be asked to undergo CT scan screening.

The diagnosis of breast cancer must be confirmed by a tissue sample, which may be obtained by several different methods. In general, the goal is to obtain tissue sufficient to make the diagnosis using the least invasive process. Fine-needle aspiration (FNA) is a common, clinic-based technique in which a thin (22- to 25-gauge) needle is placed percutaneously into the suspicious area. The site may be located by palpation if a mass can be felt. Image guidance, using ultrasound or mammography, is required for non-palpable lesions. In this situation, a non-hollow needle or marker may be placed to localize the area of suspicion. The clinician then uses the marker as a guide for the FNA. A syringe may be attached to the needle to aspirate a column of cells. Typically, multiple passes are taken from each area of interest. The aspirate is placed on a slide, air-dried, and then “fixed” by spraying or immersion with appropriate solutions. The slide is then stained and reviewed microscopically. The diagnosis can be made while the patient is still in the facility, allowing for counseling and treatment planning to be done at the same visit as the procedure. FNA is highly operator-dependent, requiring a skilled and experienced clinician to obtain consistent results.

Core-needle biopsy is similar to FNA but uses a larger-bore needle and local anesthetics. Core biopsy can also be done in a clinic setting to provide immediate results. Incisional or excisional biopsies are typically done in an operating room setting, with local anesthesia and intravenous sedation. Excisional biopsy requires the surgeon to remove the mass with a margin of normal-appearing tissue around it and is considered the definitive diagnostic method. An excisional biopsy may also be considered therapeutic, if the patient desires breast conservation [3].

There has been significant recent controversy in both medical and lay communities over the current breast cancer screening guidelines. The American Cancer Society Guidelines include the following:

In contrast, the U.S. Preventive Services Task Force has stated that insufficient evidence exists to demonstrate any benefit of annual mammography done between the ages of 40 and 49 or over 74, including clinical breast exams, self-breast exams, digital mammography, or MRI. They recommend biennial mammography screening beginning at age 50 and ending at age 75.

These recommendations have generated many negative responses from lay and medical spokespersons, with the major criticisms centered on the reduction in the use of mammography [4]. As of this writing, most professional societies, including the American Cancer Society and the American College of Obstetrics and Gynecology, have not made any changes in their recommendations for breast cancer screening. From a practical standpoint, eliminating annual mammography screening in favor of biennial screening between ages 50 and 74 is likely to have unintended negative consequences for women’s overall health maintenance and disease prevention. Similar to the Pap smear, women often view the mammogram as part of an annual “package” of health maintenance measures, including a visit to the primary care physician’s office. The current reality in the United States is that despite annual recommendations for these tests, many women have them done far less often. If the recommendation for that package of services is decreased from once a year to every 2 years (or an even longer gap), it seems reasonable to anticipate that many women will seek healthcare screening or maintenance even less often, if at all.

The gynecologist in practice should individualize screening strategies for each patient, taking recent reports into consideration as part of a frank discussion of the limitations of existing data. It is likely that screening recommendations will be further refined in the coming years as healthcare outcomes research becomes more robust, thereby requiring the gynecologist to review their practices on an ongoing basis.