The high-level flow diagram identifies several different patient populations based on a patient’s symptoms, past medical history and previous screening results. The flow diagram also points to the corresponding guidelines that outline how that patient should be cared for. The mid-level flow diagram (which is divided across several pages) provides a more detailed view of the logic. It describes how population criteria are defined and decision points that identify relevant guidelines and patient-specific recommendations.
Breast Cancer Screening High-Level Flow Diagram Primary screening decision Care delivery and follow-up Risk reduction Logic Path 1 Screening Eligible Logic Path 2 Decision to Screen Logic Path 3 High Risk Exclusions Special Populations Average Risk American Cancer Society Recommendations for the Early Detection of Breast Cancer. Last Revised: December 19, 2023. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA: a cancer journal for clinicians. 2007. US Preventive Services Task Force. Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. Published online April 30, 2024. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. Jama. 2015 Oct 20. American Cancer Society Recommendations for the Early Detection of Breast Cancer. Last Revised: December 19, 2023. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA: a cancer journal for clinicians. 2007. Logic Path 4 Due for Screening Logic Path 5 Screening Test Incomplete Logic Path 6 Follow-up Screening Result Test resulted Report Report Logic Path 1 Screening Eligible Logic Path 7 Genetic Risk Referral Logic Path 8 High Risk Referral US Preventive Services Task Force. BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing. Revised August 20, 2019. US Preventive Services Task Force. Breast Cancer: Medication Use to Reduce Risk. Revised September 03, 2019. no yes
In certain clinical scenarios, portions of the relevant National Comprehensive Cancer Network® (NCCN®) guidelines listed below were referenced. These are in select use cases where the primary guidelines did not provide specific or actionable criteria for patient stratification rather than for guidance or recommendations.
National Comprehensive Cancer Network. Breast Cancer Screening and Diagnosis (Version 2.2023).
National Comprehensive Cancer Network. Breast Cancer Risk Reduction (Version 1.2024).
National Comprehensive Cancer Network. Breast, Ovarian, and/or Pancreatic Cancer Genetic Assessment (Version 2.2024).
Breast Cancer Screening Mid-Level Flow Diagrams Primary screening decision Logic Path 1 Screening Eligible Logic Path 2 Decision to Screen Logic Path 3 High Risk Exclusions Special Populations Assigned female at birth? Current breast cancer? Past bilateral mastectomy? New or worsening breast disease symptoms? New or worsening breast exam findings? Refer to Oncologic care plan Obtain diagnostic testing Patient is eligible for screening Age > 74? Discuss decision to continue screening Indicators of reduced life expectancy? Discuss decision to continue screening if life expectancy < 10 years High risk exclusion recommendations Special population recommendations High risk exclusions or special population? Currently lactating? Consider delay if average risk Average Risk recommendations Genetic marker or syndrome? BRCA1/2, Li-Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba? History of chest radiation ages 10-30 y? Age >= 25 and >= 8 y after RT? Previous breast cancer? In remission < 5 y? Previous atypical biopsy? Lifetime risk of breast cancer > 20% or 25% Annual screening mammogram starting age 30 Refer to specialist recommendations Start screening after age 25 years and >= 8 y after RT Annual screening mammogram starting age 30 Refer to Oncologic care plan Annual screening MRI starting age 30 No exclusions for USPSTF screening pathway Patient populations Lifetime risk of breast cancer > 20% or 25% First degree relative with genetic marker or syndrome BI-RADS breast density category C or D Compelling family history of breast cancer yes no yes no yes no yes no yes no yes no no yes no yes yes no yes yes no yes no yes yes no yes no no no no
Breast Cancer Screening Mid-Level Flow Diagrams Care Delivery and Follow-up Mid-Level Flow Diagrams Logic Path 4 Due for Screening Logic Path 5 Screening Test Incomplete Logic Path 6 Follow-up Screening Result Next due date is available? Age 40-74 without screening in past 27 months? Selected interval for screening? Due for screening? Due for annual screening? Due for biennial screening? Flag overdue Order screening mammogram Determine next due date Order screening MRI if eligible Patient populations Last mammogram result is BI-RADS 0 Pending mammography order without subsequent report Pending MRI order without subsequent report Pending biopsy order without subsequent report Pending specialty referral without subsequent consult note Latest screening test type? Actionable BI-RADS? BI-RADS score? Pathology result? Update next due date Order interval imaging Referral for biopsy Specialist referral Referral for high risk evaluation Referral for excisional biopsy Referral for excisional biopsy yes no yes unknown annual biennial overdue overdue overdue due due due mammogram mri no yes bi-rads 3 bi-rads 4 or 5 biopsy malignant atypical indeterminate discordant negative
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