Breast Cancer Screening in High-Risk Women

There is circumstantial evidence that population-based screening programmes can reduce breast cancer mortality in women aged 40–70 years old. The value of screening in highrisk groups such as women with a positive family history of breast cancer is unproven. In the meantime a rapidly increasing number of high-risk women seek counselling about strategies to reduce their risk of breast cancer death, such as intensive surveillance. As for ethical reasons no randomized trials can be performed, the effect of screening these women has to be evaluated by means of observational studies. In several specialized centers in the Netherlands, women with a more than 2 times increased risk of breast cancer (BC) (lifetime > 15%) are being screened regularly. In this study the first results of screening highrisk women in the Rotterdam Cancer Center/ University Hospital are described.


Introduction
In 2018, the American Cancer Society projects breast cancer to be the most frequently diagnosed non-dermatologic malignancy (266,120 new cases) and the second leading cause of cancer death (40,920 deaths) among women in the United States. 1 The annual national expenditure in the United States for treatment of breast cancer was estimated to be $39 billion in 2017. 2 Although the impact of population screening for breast cancer in low-and average-risk women are well reviewed, 3 evidence on the effectiveness and harms of breast cancer screening in high-risk women have not been adequately synthesized and subsequent practice guidelines have not been well developed. In addition, controversy remains regarding the criteria to properly categorize breast cancer risk among women with greater than average risk. 4

Methods
To assess topic nomination Breast Cancer Screening in High-Risk Women #739, for priority for a systematic review or other AHRQ EHC report, we used a modified process based on established criteria. Our assessment is hierarchical in nature, with the findings of our assessment determining the need for further evaluation. Details related to our assessment are provided in Appendix A.
1. Determine the appropriateness of the nominated topic for inclusion in the EHC program. 2. Establish the overall importance of a potential topic as representing a health or healthcare issue in the United States. 3. Determine the desirability of new evidence review by examining whether a new systematic review or other AHRQ product would be duplicative. 4. Assess the potential impact a new systematic review or other AHRQ product. 5. Assess whether the current state of the evidence allows for a systematic review or other AHRQ product (feasibility). 6. Determine the potential value of a new systematic review or other AHRQ product.

Appropriateness and Importance
We qualitatively assessed the nomination for appropriateness and importance.

Desirability of New Review/Duplication
We searched for relevant high quality, completed or in-process evidence reviews from the last three years. Databases searched included AHRQ Effective Health Care Program website, VA Evidence Synthesis Program website, PubMed, Cochrane Collaboration, and PROSPERO register of systematic reviews.

Compilation of Findings
We constructed a table outlining the selection criteria (Appendix A).

Appropriateness and Importance
This is an appropriate and important topic. Breast cancer represents both high mortality burden for women as well as high cost burden in the United States.

Desirability of New Review/Duplication
A new evidence review examining breast cancer screening in high-risk women would be duplicative of an existing product. A systematic review, which encompasses the scope of the topic nomination, was commissioned by a cancer organization in the United States to update their guidelines. We have withheld the organization name because they have not publicly disclosed these efforts. In addition, we found three reviews that are relevant to KQ2. [5][6][7] One review focused on the contribution of mammography to magnetic resonance imaging (MRI) screening in BRCA mutation carriers. 5 One review examined screening MRI in women with a personal history of breast cancer 6 and another review assesses ultrasound as an adjunct to mammography. 7 See Table 2, Duplication column for the systematic review citations that were determined to address the key questions. Total number of completed or in-progress evidence reviews -None identified KQ 2: What is the effectiveness of breast cancer screening in reducing breast cancer incidence in asymptomatic high-risk women?
Total number of completed or in-progress systematic reviews -3 • Other -3 [5][6][7] KQ 3: What are the harms of breast cancer screening in asymptomatic high-risk women?
Total number of completed or in-progress evidence reviews -None identified

Summary of Findings
• Appropriateness and Importance: The topic is both appropriate and important.
• Duplication: A new review on this topic would be duplicative of an existing product. A systematic review, which encompasses the scope of the topic nomination, is currently underway.