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CDC Breast Cancer Screening CDS L2

Introduction

Introduction

This document includes a semi-structured representation of evidence-based narrative guidelines for breast cancer screening. Semi-structured representation, also known as Level 2 representation, of guideline content and recommendations is essential for the development of computable clinical decision support (CDS) artifacts. It includes:

  1. High-level and mid-level flow diagrams that visually illustrate portions of the guidelines.
  2. A brief description of each portion of the CDS logic.
  3. Semi-structured logic statements that list required clinical concepts, inclusion criteria, exclusion criteria, events (decision points), and actions (output, e.g. recommendations).

How to Navigate the Specification

Start with Pathway. This page includes:

  • High-level flow diagram, which visually illustrates the main logic paths translated, applicable guidelines, and order of precedence and dependencies among logic paths.
  • A combined view of mid-level flow diagrams, which provide a more detailed view of each logic path and how they relate to each other.

Each logic path has a dedicated page under Logic Paths, which includes the mid-level flow diagram for the path, as well as semi-structured logic statements. These may refer to:

  • Data elements: logic statements used multiple times across the specification; and
  • Terminology: clinical concepts that will eventually be represented by lists of codes.

Pathway

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.

High-Level Flow Diagram

Breast Cancer Screening High-Level Flow DiagramPrimary screening decisionCare delivery and follow-upRisk reductionLogic Path 1Screening EligibleLogic Path 2Decision to ScreenLogic Path 3High Risk ExclusionsSpecial PopulationsAverage RiskAmerican Cancer Society Recommendations for the EarlyDetection of Breast Cancer. Last Revised: December 19,2023.American Cancer Society guidelines for breast screeningwith MRI as an adjunct to mammography. CA: a cancerjournal for clinicians. 2007.US Preventive Services Task Force. Screening for BreastCancer: US Preventive Services Task ForceRecommendation Statement. JAMA. Published online April30, 2024.Breast cancer screening for women at average risk: 2015guideline update from the American Cancer Society. Jama.2015 Oct 20.American Cancer Society Recommendations for the EarlyDetection of Breast Cancer. Last Revised: December 19,2023.American Cancer Society guidelines for breast screeningwith MRI as an adjunct to mammography. CA: a cancerjournal for clinicians. 2007.Logic Path 4Due for ScreeningLogic Path 5Screening Test IncompleteLogic Path 6Follow-up Screening ResultTest resultedReportReportLogic Path 1Screening EligibleLogic Path 7Genetic Risk ReferralLogic Path 8High Risk ReferralUS Preventive Services Task Force. BRCA-Related Cancer:Risk Assessment, Genetic Counseling, and GeneticTesting. Revised August 20, 2019.US Preventive Services Task Force. Breast Cancer:Medication Use to Reduce Risk. Revised September 03,2019.noyes

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).

Mid-level flow diagrams

Screening Decision Mid-level Flow

Breast Cancer Screening Mid-Level Flow DiagramsPrimary screening decisionLogic Path 1Screening EligibleLogic Path 2Decision to ScreenLogic Path 3High Risk ExclusionsSpecial PopulationsAssigned female atbirth?Current breastcancer?Past bilateralmastectomy?New or worseningbreast diseasesymptoms?New or worseningbreast exam findings?Refer to Oncologic care planObtain diagnostic testingPatient is eligible for screeningAge > 74?Discuss decision to continuescreeningIndicators of reducedlife expectancy?Discuss decision to continuescreening if life expectancy < 10yearsHigh risk exclusionrecommendationsSpecial populationrecommendationsHigh risk exclusionsor special population?Currently lactating?Consider delay if average riskAverage Risk recommendationsGenetic marker orsyndrome?BRCA1/2,Li-Fraumeni,Cowden, orBannayan-Riley-Ruvalcaba?History of chestradiation ages 10-30y?Age >= 25 and >= 8y after RT?Previous breastcancer?In remission < 5 y?Previous atypicalbiopsy?Lifetime risk of breastcancer > 20% or 25%Annual screening mammogramstarting age 30Refer to specialist recommendationsStart screening after age 25 yearsand >= 8 y after RTAnnual screening mammogramstarting age 30Refer to Oncologic care planAnnual screening MRI starting age30No exclusions for USPSTF screeningpathwayPatient populationsLifetime risk of breast cancer > 20% or 25%First degree relative with genetic marker or syndromeBI-RADS breast density category C or DCompelling family history of breast canceryesnoyesnoyesnoyesnoyesnoyesnonoyesnoyesyesnoyesyesnoyesnoyesyesnoyesnononono

Care Delivery and Follow-up Mid-Level Flow

Breast Cancer Screening Mid-Level Flow DiagramsCare Delivery and Follow-up Mid-Level Flow DiagramsLogic Path 4Due for ScreeningLogic Path 5Screening Test IncompleteLogic Path 6Follow-up Screening ResultNext due date isavailable?Age 40-74 withoutscreening in past 27months?Selected interval forscreening?Due for screening?Due for annualscreening?Due for biennialscreening?Flag overdueOrder screening mammogramDetermine next due dateOrder screening MRI if eligiblePatient populationsLast mammogram result is BI-RADS 0Pending mammography order without subsequent reportPending MRI order without subsequent reportPending biopsy order without subsequent reportPending specialty referral without subsequent consult noteLatest screening testtype?Actionable BI-RADS?BI-RADS score?Pathology result?Update next due dateOrder interval imagingReferral for biopsySpecialist referralReferral for high risk evaluationReferral for excisional biopsyReferral for excisional biopsyyesnoyesunknownannualbiennialoverdueoverdueoverdueduedueduemammogrammrinoyesbi-rads 3bi-rads 4 or 5biopsymalignantatypicalindeterminatediscordantnegative

Logic Paths

Semi-structured logic statements are comprised of three “sections” or components, each with a distinct purpose:

  • Inclusion - describes target population criteria
  • Exclusion - removes individuals from the target population based on evidence-based recommendations
  • CDS Events - describes a decision point or trigger in the logic that leads to a recommendation or action
  • CDS Actions - describes one or more “products” (e.g., calculations, recommendations) that the logic provides for a patient that meets the inclusion criteria, is not removed by the exclusion criteria, and meets the event criteria

Screening Eligible

Description

Determines whether a patient is eligible for routine breast cancer screening. This includes absolute exclusion criteria for which routine screening is not indicated in all guidelines and pathways.

Individuals who have certain signs or symptoms concerning for breast cancer or other breast diseases are excluded from routine screening pathways and should have diagnostic testing performed.

Mid-Level Flow Diagram

Assigned female atbirth?Current breastcancer?Past bilateralmastectomy?New or worseningbreast diseasesymptoms?New or worseningbreast exam findings?endRefer to Oncologic care planObtain diagnostic testingPatient is eligible for screeningyesnonoyesnoyesyesnoyesno

Semi-Structured Logic Statements

Inclusions

NameDescription
Age 18 years and older
Even for high risk individuals, routine clinical monitoring or screening is not recommended prior to age 21 y and risk reduction modalities are generally not offered at this age.
Source: NCCN
Patient age >= 18
Assigned female at birth or Transgender male
Implemented guidelines address persons assigned female at birth, however there are specialty guidelines that address routine screening for transgender individuals.
'Assigned female at birth' is TRUE
OR
gender identity = transgender male

Exclusions

None.

Events

NameDescription
Assigned female at birth?
Referenced guidelines apply to individuals assigned female at birth. Routine screening of cis-gender individuals assigned male at birth is not recommended. For transgender women, consider specialist referral.

Additional resources: ACR Appropriateness Criteria® Transgender Breast Cancer Screening; UCSF guidelines 'Screening for breast cancer in transgender women'
Current breast cancer?
Diagnosis of breast cancer within past 5 years
'Current breast cancer' is TRUE AND onset within 5 years
OR
'Previous breast cancer' is TRUE AND onset within 5 years
Past bilateral mastectomy?
Excludes breast reduction.
New or worsening breast disease symptoms?
Excludes past breast symptoms which have since resolved, and chronic, stable breast symptoms for which diagnostic testing was done and found to be benign.

Cyclical unilateral or bilateral breast pain at any age and noncyclical diffuse unilateral or bilateral pain in age < 40 years are unlikely to represent malignancy and can continue with routine screening in the absence of other concerning factors (source: ACR).
Current 'Breast symptoms' exist which are new onset or progressively worsening
New or worsening breast exam findings?
Excludes past breast exam findings which have since resolved, and chronic, stable breast findings for which diagnostic testing was done and found to be benign unless further diagnostic testing is recommended by specialist.
Current 'Breast exam findings' exist which are new onset or progressively worsening

Actions

Obtain diagnostic testing
Description
New breast symptoms or exam findings, or chronic symptoms or findings which have progressively worsened, should undergo diagnostic testing rather than routine screening.
Pseudocode
Refer to Oncologic care plan
Description
Breast cancer diagnosed within 5 years may require enhanced surveillance including diagnostic mammogram.

Refer to patient's Oncologic treatment team or Survivorship Care Plan for patient specific guidance.
Pseudocode
Patient is eligible for screening
Description
Pseudocode

Decision to Screen

Description

Evaluate criteria to determine age to start and age to stop, screening modality, and screening interval.

Mid-Level Flow Diagram

Age > 74?Discuss decision to continuescreeningIndicators of reducedlife expectancy?Discuss decision to continuescreening if life expectancy < 10yearsHigh risk exclusionrecommendationsSpecial populationrecommendationsHigh risk exclusionsor special population?Currently lactating?Consider delay if average riskendAverage Risk recommendationsyesnoyesnoyesnoyesno

Semi-Structured Logic Statements

Inclusions

None.

Exclusions

NameDescription
Patient is not eligible for screening
See 'Screening Eligible' flow logic

Events

NameDescription
Age > 74?
Age > 74 years
Patient age > 74 years
Indicators of reduced life expectancy?
Patient has conditions or meets criteria that indicate reduced life expectancy.
Currently lactating?
Patient is currently lactating or breast feeding.
OBSERVATIONS include `Lactating or Breastfeeding`
High risk exclusions or special population?
Patient meets criteria for patient population excluded from USPSTF recommendation statement or meets criteria for patient population identified as having higher than average risk in ACS guidelines.

Actions

Discuss decision to continue screening
Description
The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of screening mammography in women 75 years or older.

Decision to continue screening mammography in average risk women should be based on shared decision-making.
Pseudocode
Discuss decision to continue screening if life expectancy < 10 years
Description
ACS advises that women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or more.

Life expectancy is generally defined as having greater than a 50% probability of surviving 10 years. A validated tool such as www.eprognosis.com can help guide decision making.

Decision to continue screening mammography in cases of limited life expectancy should be based on shared decision-making.
Pseudocode
High risk exclusion recommendations
Description
Evaluate for high risk exclusion criteria
Pseudocode
See 'High Risk Exclusions' flow logic
Special population recommendations
Description
Evaluate for special population criteria
Pseudocode
See 'Special Populations' flow logic
Consider delay if average risk
Description
There is no contraindication to screening mammography during lactation, however sensitivity and specificity are decreased. For average risk patients, consider a short delay in routine breast imaging until after lactation, particularly if they are not planning prolonged breastfeeding.

Source: NCCN
Pseudocode
Average Risk recommendations
Description
Evaluate for average risk criteria
Pseudocode
See 'Average Risk' flow logic

High Risk Exclusions

Description

Clinical characteristics that have been identified in the USPSTF breast screening recommendation statement as indicative of higher than average risk and therefore excluded from recommendation statement patient population. Provides criteria to determine age to start and age to stop, screening modality, and screening interval for these populations of patients.

Mid-Level Flow Diagram

Genetic marker orsyndrome?BRCA1/2,Li-Fraumeni,Cowden, orBannayan-Riley-Ruvalcaba?History of chestradiation ages 10-30y?Age >= 25 and >= 8y after RT?Previous breastcancer?In remission < 5 y?Previous atypicalbiopsy?Lifetime risk of breastcancer > 20% or 25%Annual screening mammogramstarting age 30Refer to specialist recommendationsStart screening after age 25 yearsand >= 8 y after RTAnnual screening mammogramstarting age 30Refer to Oncologic care planAnnual screening MRI starting age30No exclusions for USPSTF screeningpathwayyesyesnoyesyesnoyesnoyesyesnoyesnononono

Semi-Structured Logic Statements

Inclusions

None.

Exclusions

NameDescription
Patient is not eligible for screening
See 'Screening Eligible' flow logic

Events

NameDescription
Genetic marker or syndrome?
History of chest radiation ages 10-30 y?
Thoracic radiation therapy between ages 10 and 30 years
'History of high-dose radiation therapy to the chest' with age at treatment start >= 10 years and <= 30 years OR age at treatment end >= 10 years and <= 30 years
Age >= 25 and >= 8 y after RT?
Patient age is 25 years or older and currently is >= 8 years after RT completion
Patient age >= 25 years
AND
>= 8 years after completion of 'History of high-dose radiation therapy to the chest'
Previous breast cancer?
History of invasive or non-invasive breast cancer.
In remission < 5 y?
Breast cancer in remission < 5 years duration?
'Previous breast cancer' is TRUE AND end date < 5 years ago
Previous atypical biopsy?
High risk benign histology on past breast biopsy, including ADH, ALH and LCIS.
Lifetime risk of breast cancer > 20% or 25%
Estimated lifetime risk is >20%, based on informal assessment or assessment using validated risk model
BRCA1/2, Li-Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba?
History of known BRCA1/2 variants, Li-Fraumeni syndrome (TP53 variant), Cowden or Bannayan-Riley-Ruvalcaba syndromes (PTEN variants).

Actions

Refer to specialist recommendations
Description
A number of other genetic variants are known to be associated with an increased risk of developing of breast cancer. For known personal history of these variants, refer to the consulting geneticist or to high risk breast specialist for guidance on routine screening. Variants may include ATM, BARD1, CDH1, CHEK2, NF1, PALB2, RAD51C, RAD51D, STK11.
Pseudocode
Annual screening mammogram starting age 30
Description
Source: ACS
Women who are at higher than average risk for breast cancer based on certain factors should get a mammogram every year, typically starting at age 30.
Pseudocode
Screening age = >= 30
Screening modality = mammography
Screening interval = annual
Next due date = date patient is 30 years old if age < 30
OR
Next due date = 'Date of last mammography' plus 1 year OR Now if 'Last mammography' does not exist
Annual screening MRI starting age 30
Description
Source: ACS
Women who are at higher than average risk for breast cancer based on certain factors should get a breast MRI every year, typically starting at age 30.
Pseudocode
Screening age = >= 30
Screening modality = mri
Screening interval = annual
Next due date = date patient is 30 years old if age < 30
OR
Next due date = 'Date of last MRI' plus 1 year, if exists
OR
Next due date = 'Date of last mammography' plus 1 year, if exists
OR
Next due date = Now if 'Last MRI' and 'Last mammography' do not exist
Annual screening mammogram starting age 30
Description
Source: ACS
Women who are at high risk for breast cancer based on certain factors should get a mammogram every year, typically starting at age 30. There’s not enough evidence to make a recommendation for or against yearly MRI screening for women who have a higher lifetime risk based on certain factors.
Pseudocode
Screening age = >= 30
Screening modality = mammography
Screening interval = annual
Next due date = date patient is 30 years old if age < 30
OR
Next due date = 'Date of last mammography' plus 1 year
OR
Next due date = Now if 'Last mammography' does not exist
Start screening after age 25 years and >= 8 y after RT
Description
Start at age 25 years or >= 8 years from radiation, whichever occurs last.
Source: ACR, NCCN

Refer to patient's Oncologic treatment team or Survivorship Care Plan for patient specific guidance.
Pseudocode
Next due date = latest of date patient is 25 years old or date of >= 8 years after completion of RT
Refer to Oncologic care plan
Description
Previous breast cancer within 5 years may require enhanced surveillance including diagnostic mammogram.

Refer to patient's Oncologic treatment team or Survivorship Care Plan for patient specific guidance.
Pseudocode
Next due date = refer to Oncologic care plan
No exclusions for USPSTF screening pathway
Description
Patient does not meet exclusion criteria for USPSTF average risk breast cancer screening recommendations.
Pseudocode

Special Populations

Description

Patient population that have been identified as higher than average risk or otherwise requiring specific consideration within a particular guideline. Provides criteria to determine age to start, screening modality, and screening interval for these populations of patients.

Mid-Level Flow

Patient population Age group Source Recommendation
Lifetime risk of breast cancer > 20% or 25% <30 ACS Start screening at 30 years old
Lifetime risk of breast cancer > 20% or 25% <30 USPSTF Start screening at 40 years old
Lifetime risk of breast cancer > 20% or 25% 30-39 ACS Annual screening mammogram
Annual screening MRI
Lifetime risk of breast cancer > 20% or 25% 30-39 USPSTF Start screening at 40 years old
Lifetime risk of breast cancer > 20% or 25% >=40 ACS Annual screening mammogram
Annual screening MRI
Lifetime risk of breast cancer > 20% or 25% >=40 USPSTF Biennial screening mammogram
First degree relative with genetic marker or syndrome <30 ACS Start screening at 30 years old
First degree relative with genetic marker or syndrome <30 USPSTF Start screening at 40 years old
First degree relative with genetic marker or syndrome 30-39 ACS Annual screening mammogram
Annual screening MRI
First degree relative with genetic marker or syndrome 30-39 USPSTF Start screening at 40 years old
First degree relative with genetic marker or syndrome >=40 ACS Annual screening mammogram
Annual screening MRI
First degree relative with genetic marker or syndrome >=40 USPSTF Biennial screening mammogram
BI-RADS breast density category C or D? <40 ACS Perform lifetime risk assessment
BI-RADS breast density category C or D? <40 USPSTF Start screening at 40 years old
BI-RADS breast density category C or D? >=40 ACS Perform lifetime risk assessment
BI-RADS breast density category C or D? >=40 USPSTF Biennial screening mammogram
Compelling family history of breast cancer <40 ACS Perform lifetime risk assessment
Compelling family history of breast cancer <40 USPSTF Start screening at 40 years old
Compelling family history of breast cancer >=40 ACS Perform lifetime risk assessment
Compelling family history of breast cancer >=40 USPSTF Biennial screening mammogram

Semi-Structured Logic Statements

Inclusions

None.

Exclusions

None.

Events

NameDescription
Patient population
Population to which the patient fits criteria
Age group
Patient age group
Source
Source of recommendation
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
Pedigree of blood relatives on both maternal and paternal side includes compelling history of breast cancer.
'Compelling family history of breast cancer' is true
<30
Patient age < 30 years
30-39
Patient age >= 30 and <=39
>=40
Patient age >=40
<40
Patient age < 40 years
ACS
Source of recommendation is ACS
USPSTF
Source of recommendation is USPSTF
NCCN
Source of recommendation is NCCN

Actions

Start screening at 30 years old
Description
Source: ACS
Pseudocode
Next due date = date patient is 30 years old
Start screening at 40 years old
Description
Source: USPSTF
Pseudocode
Next due date = date patient is 40 years old
Annual screening mammogram
Description
Source: ACS
Women who are at high risk for breast cancer based on certain factors should get a breast MRI and a mammogram every year, typically starting at age 30.
Pseudocode
Screening age = >= 30
Screening modality = mammography
Screening interval = annual
Next due date = 'Date of last mammography' plus 1 year OR Now if 'Last mammography' does not exist
Annual screening MRI
Description
Source: ACS
Women who are at high risk for breast cancer based on certain factors should get a breast MRI and a mammogram every year, typically starting at age 30.
Pseudocode
Screening age = >= 30
Screening modality = MRI
Screening interval = annual
Next due date = 'Date of last MRI' plus 1 year OR Now if 'Last MRI' does not exist
Annual screening mammogram only
Description
Source: ACS
Women who are at high risk for breast cancer based on certain factors should get a mammogram every year, typically starting at age 30. There’s not enough evidence to make a recommendation for or against yearly MRI screening for women who have a higher lifetime risk based on certain factors.
Pseudocode
Screening age = >= 30
Screening modality = mammography
Screening interval = annual
Next due date = 'Date of last mammography' plus 1 year OR Now if 'Last mammography' does not exist
Biennial screening mammogram
Description
Source: USPSTF
Pseudocode
Screening age = >= 40
Screening modality = mammography
Screening interval = biennial
Next due date = 'Date of last mammography' plus 2 years OR Now if 'Last mammography' does not exist
Perform lifetime risk assessment
Description
Perform assessment of lifetime risk, as defined by models largely dependent on family history. Result of risk assessment informs next step, either proceed to recommendations for Lifetime risk of breast cancer > 20% or 25% or else patient does not meet criteria for special populations.

Validated tools include BRCAPRO, Claus, BOADICEA [Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm], and Tyrer-Cuzick.

Source: ACS
Pseudocode
Perform assessment of lifetime risk, as defined by models largely dependent on family history.

Average Risk

Description

Patient population identified as average risk. Provides criteria to determine age to start, screening modality, and screening interval for these populations of patients.

Clinical Review

Mid-Level Flow

Semi-Structured Logic Statements

Inclusions

None.

Exclusions

None.

Events

Name
Age group
Patient age group
Source
Source of recommendation
<40
Patient age < 40 years
40-44
Patient age >=40 and <=44
45-54
Patient age >=45 and <=54
>=55
Patient age >=55
ACS
Source of recommendation is ACS
USPSTF
Source of recommendation is USPSTF

Actions

Start screening at 40 years old
Description
Source: USPSTF
Pseudocode
Next due date = date patient is 40 years old
Offer annual screening mammogram
Description
Source: ACS
Women between 40 and 44 have the option to start screening with a mammogram every year.
Pseudocode
Screening age = >= 40 and <44
Screening modality = mammography
Screening interval = annual
Next due date = 'Date of last mammography' plus 1 year OR Now if 'Last mammography' does not exist
Annual screening mammogram
Description
Source: ACS
Women 45 to 54 should get mammograms every year.
Pseudocode
Screening age = >= 45 and <54
Screening modality = mammography
Screening interval = annual
Next due date = 'Date of last mammography' plus 1 year OR Now if 'Last mammography' does not exist
Biennial screening mammogram or continue screening annually
Description
Source: ACS
Women 55 and older can switch to a mammogram every other year, or they can choose to continue yearly mammograms. Screening should continue as long as a woman is in good health and is expected to live at least 10 more years.
Pseudocode
Screening age = >= 55
Screening modality = mammography
Screening interval = biennial OR annual
Next due date = 'Date of last mammography' plus 1 or 2 years OR Now if 'Last mammography' does not exist
Biennial screening mammogram
Description
Pseudocode
Screening age = >= 40
Screening modality = mammography
Screening interval = biennial
Next due date = 'Date of last mammography' plus 2 years OR Now if 'Last mammography' does not exist

Genetic Risk Referral

Description

Risk assessment for women who have family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes to determine who should receive referral for genetic counseling and, if indicated after counseling, testing.

Mid-Level Flow Diagram

Family history ofinherited cancersusceptibility?Unknown variantstatus?Ancestry associatedwith BRCA1/2 genemutations?Family history ofbreast, ovarian, tubal,or peritoneal cancerSelected method forfamilial riskassessmentBrief familial risk assessment toolInformal familial risk assessmentFamily history riskassessment result?endReferral for genetic counselingendendyesnoyesnoyesnonoyesformalinformalpositivenegative

Semi-Structured Logic Statements

Inclusions

NameDescription
Age 18 years and older
In children <18 y, genetic testing is generally not recommended when results would not impact medical management.
Source: NCCN
Patient age >= 18
Assigned female at birth
Referenced guidelines apply to individuals assigned female at birth. For transgender women, refer to specialty guidelines.

Exclusions

NameDescription
Patient is not eligible for screening
See 'Screening Eligible' flow logic

Events

NameDescription
Family history of inherited cancer susceptibility?
Any blood relative with known BRCA1/BRCA2 variants, Li-Fraumeni syndrome (TP53 variant), Cowden or Bannayan-Riley-Ruvalcaba syndromes (PTEN variants), and other variants known to be associated with increased risk of development of breast cancer. Variants may include ATM, BARD1, CDH1, CHEK2, NF1, PALB2, RAD51C, RAD51D, STK11.
'Family history of known BRCA1/2 mutation' is TRUE
OR
Family history of other variant of concern
Unknown variant status?
Not previously tested for BRCA1/BRCA2 variants or other variant of concern based on known family history.
DOES NOT EXIST 'BRCA-1 mutation diagnosis' OR 'BRCA-2 mutation diagnosis' OR 'BRCA-1 mutation test' OR 'BRCA-2 mutation test'
OR
DOES NOT EXIST prior genetic testing panel including variant of concern
Family history of breast, ovarian, tubal, or peritoneal cancer
Pedigree of blood relatives on both maternal and paternal side including asking about specific types of cancer, primary cancer sites, which family members were affected, whether relatives had multiple types of primary cancer, age at diagnosis, age at death, and sex of affected family members.
Ancestry associated with BRCA1/2 gene mutations?
Can offer testing to individuals who have one grandparent identified as of Ashkenazi Jewish ancestry, irrespective of cancer history in the family and without additional risk factors (source: NCCN).
Ashkenazi Jewish ancestry in at least one grandparent
Selected method for familial risk assessment
Method by which to perform assessment of risk of inherited variant associated with breast cancer susceptibility
FORMAL OR INFORMAL
Family history risk assessment result?
Result of familial risk assessment, either formal using a validated risk tool or informal using clinician judgement
Output of validated brief familial risk assessment tool is positive, as defined by tool itself
OR
Probability >5% of a BRCA1/2 P/LP variant based on prior probability models, if model does not provide cutoff
OR
Informal familial risk assessment suggestive of higher than average risk of genetic variant

Actions

Brief familial risk assessment tool
Description
Tools evaluated by the USPSTF include the Ontario Family History Assessment Tool, Manchester Scoring System, Referral Screening Tool, Pedigree Assessment Tool, 7-Question Family History Screening Tool, International Breast Cancer Intervention Study instrument (Tyrer-Cuzick), and brief versions of BRCAPRO.

Source: USPSTF
Pseudocode
Informal familial risk assessment
Description
Perform assessment based on criteria in first- or second-degree blood relatives known to be associated with increased risk of inherited breast cancer susceptibility variant.
Source: ACS
Pseudocode
Referral for genetic counseling
Description
Referral for genetic counseling if not previously consulted, or if limited panel was done and additional testing may be warranted.
Source: USPSTF
Pseudocode
REFERRAL for genetic counseling

High Risk Referral

Description

Women who are at increased risk for breast cancer without current or previous diagnosis of breast cancer or ductal carcinoma in situ (DCIS) can be referred to a breast specialty clinic to consider risk reduction interventions.

Mid-Level Flow

Semi-Structured Logic Statements

Inclusions

NameDescription
Age 18 years and older
Even for high risk individuals, routine clinical monitoring or screening is not recommended prior to age 21 y and risk reduction modalities are generally not offered at this age.
Source: NCCN
Patient age >= 18
Assigned female at birth
Referenced guidelines apply to individuals assigned female at birth. For transgender women, refer to specialty guidelines.

Exclusions

NameDescription
Patient is not eligible for screening
See 'Screening Eligible' flow logic
Previous diagnosis of breast cancer
No indication for primary risk reduction in patient with breast cancer in remission. Secondary risk reduction would be determined by Oncologic team.

Events

NameDescription
Patient population
Population to which the patient fits criteria
Age group
Patient age group
Any
Any age
>= 35
Patient age >= 35 years
Genetic marker or syndrome
History of chest radiation
Previous high-risk finding on biopsy
High-risk benign pathology on previous breast biopsy, particularly ADH, LCIS, ALH.
5 year risk >= 3%
Estimated 5 year risk of breast cancer, either performed using formal assessment model or informal assessment, is >= 3%
Formal clinical risk assessment tool output suggests 5 year risk >= 3%
OR
assessment of breast cancer risk factors without using a formal tool suggests higher than average risk
5 year risk >= 1.67%
Estimated 5 year risk of breast cancer, either performed using formal assessment model or informal assessment, is >= 1.67%
Formal clinical risk assessment tool output suggests 5 year risk >= 1.67%
OR
assessment of breast cancer risk factors without using a formal tool suggests higher than average risk
Compelling family history of breast cancer
Pedigree of blood relatives on both maternal and paternal side includes compelling history of breast cancer.
'Compelling family history of breast cancer' is true
Personal risk factors conferring increased risk of breast cancer
Patient has risk factors that contribute to risk of developing breast cancer. These may include increasing age, younger age at menarche, older age at first live birth, nulliparity/lower parity, number of prior breast biopsies, heterogeneously and/or extremely dense breasts.
EXISTS > 1 DIAGNOSTIC REPORT of type `BREAST BIOPSY`
OR
BI-RADS breast density score in 'Last mammography result' is C OR D

Actions

Consider life expectancy
Description
Patient may not be a candidate for chemoprevention if estimated life expectancy is < 10 years. Factors that may impact this estimation should be considered prior to referral. A validated tool such as www.eprognosis.com can help guide decision making.
Pseudocode
Referral for high risk breast specialty evaluation
Description
Consider referral to breast specialist to discuss primary risk reduction interventions such as chemoprevention. Women at greater risk, such as those with at least a 3% risk for breast cancer in the next 5 years, are likely to derive more benefit than harm from risk-reducing medications.

Source: USPSTF
Pseudocode
REFERRAL for high risk breast clinic evaluation if none previously
Consider referral for high risk breast specialty evaluation
Description
Consider referral to breast specialist to discuss primary risk reduction interventions such as chemoprevention.

Source: USPSTF
Pseudocode
REFERRAL for high risk breast clinic evaluation if none previously
Perform risk assessment
Description
The NCI Breast Cancer Risk Assessment Tool and the Breast Cancer Surveillance Consortium Risk Calculator are based on models tested in US populations and are publicly available for clinicians and patients to use as part of the process of shared, informed decision-making about taking risk-reducing medications for breast cancer.

Source: USPSTF
Pseudocode
Perform risk assessment using a formal clinical risk assessment tool
OR
Perform assessment of breast cancer risk factors without using a formal tool

Due for Screening

Description

Identifies patient who may be due for screening based on prior assessment and documentation of next due date and flags patient who may be overdue for potential enhanced outreach efforts.

Intended for use with either individual patient alerts, within the context of a clinical encounter or outside an encounter, or for generating asynchronous reports on a cohort/panel of patients in order to target outreach or escalation.

Mid-Level Flow Diagram

Next due date isavailable?Age 40-74 withoutscreening in past 27months?Selected interval forscreening?Due for screening?Due for annualscreening?Due for biennialscreening?Flag overdueOrder screening mammogramDetermine next due dateOrder screening MRI if eligibleendendendyesnoyesunknownannualbiennialoverdueoverdueoverdueduedueduenot duenot duenot due

Semi-Structured Logic Statements

Inclusions

None.

Exclusions

None.

Events

NameDescription
Next due date is available?
Documented next due date, based on output of previous pathways.
EXISTS next due date
Age 40-74 without screening in past 27 months?
No screening mammography within past 27 months in patient 40–74 years of age
Age is >= 40 AND age is <=74 AND ('Last mammography' does not exist OR 'Last mammography' date is > 27 months ago)
Selected interval for screening?
Documented interval for screening based on output of previous pathways, if available.
ANNUAL if preferred interval is annual
OR
BIENNIAL if preferred interval is biennial
OR
UNKNOWN if not documented
Due for screening?
Refer to next due date, which is the output of previous pathways involving assessment of patient history and risk factors, to determine whether patient is currently due for screening study, overdue or not yet due.

OVERDUE if next due date > 3 months
OR
DUE if next due date within 2 months from now OR < 3 months ago
OR
Otherwise NOT DUE
Due for biennial screening?
Refer to next due date, which is the output of previous pathways involving assessment of patient history and risk factors, to determine whether patient is currently due for screening study, overdue or not yet due.

OVERDUE if next due date > 3 months
OR
DUE if next due date within 2 months from now OR < 3 months ago
OR
Otherwise NOT DUE
Due for annual screening?
Refer to next due date, which is the output of previous pathways involving assessment of patient history and risk factors, to determine whether patient is currently due for screening study, overdue or not yet due.

OVERDUE if next due date > 2 months
OR
DUE if next due date within 2 months from now OR < 2 months ago
OR
Otherwise NOT DUE

Actions

Determine next due date
Description
Determine whether patient is eligible for screening and if so, document next due date
Pseudocode
See 'Decision to Screen' flow logic
Flag overdue
Description
Flag patient as overdue for routine screening to allow clinician alert or patient outreach
Pseudocode
Order screening mammogram
Description
Order screening mammography
Pseudocode
ORDER for screening mammography if 'Pending mammography' does not exist
Order screening MRI if eligible
Description
Order screening MRI as determined by prior assessment of patient eligibility for supplemental screening
Pseudocode
ORDER for screening MRI if 'Pending MRI' does not exist AND patient is eligible for MRI

Screening Test Incomplete

Description

Identifies patients who have been ordered for screening mammography or for follow-up study for abnormal screening mammography but for whom a study report has not been received or documented as received.

Intended for use with either individual patient alerts, within the context of a clinical encounter or outside an encounter, or for generating asynchronous reports on a cohort/panel of patients in order to target outreach or escalation.

Mid-Level Flow

Semi-Structured Logic Statements

Inclusions

NameDescription
Primary screening ordered
See 'Screening due' flow logic

Exclusions

None.

Events

NameDescription
Patient population
Population to which the patient fits criteria
Last mammogram result is BI-RADS 0?
Awaiting final amended imaging report, either due to need for further imaging or comparison with previous mammography to verify stability of a finding.
BI-RADS score in 'Last mammography result' is 0, recall to imaging center
Pending mammography order without subsequent report?
'Pending mammography' exists
AND
'Date of last mammography' does not exists OR is before date 'Pending mammography' order or referral was placed

Pending MRI order without subsequent report?
'Pending MRI' exists
AND
'Date of last MRI' does not exists OR is before date 'Pending MRI' order or referral was placed
Pending ultrasound order without subsequent report?
'Pending ultrasound' exists
AND
'Date of last ultrasound' does not exists OR is before date 'Pending ultrasound' order or referral was placed
Pending biopsy order without subsequent report?
'Pending biopsy' exists
AND
'Date of last biopsy' does not exists OR is before date 'Pending biopsy' order or referral was placed
Pending specialty referral without subsequent consult note?
Patient has an active specialty referral without a subsequent consult note of the same type.
REFERRAL where service type is `BREAST SURGERY` OR `MEDICAL ONCOLOGY` exists and status is active
AND
There does not exist a CLINICAL NOTE of service type `BREAST SURGERY` OR ` MEDICAL ONCOLOGY` with date after referral

Actions

Pending screening test
Description
Patient has incomplete screening tests
Pseudocode
Patient has incomplete screening tests

Follow-up Screening Result

Description

Determines next steps, if any, based on result of screening imaging or biopsy. This may be triggered by a diagnostic report being received by the system or a mammography BI-RADS result being documented in a structured manner.

Mid-Level Flow Diagram

Latest screening testtype?Actionable BI-RADS?BI-RADS score?Pathology result?Update next due dateOrder interval imagingReferral for biopsyendSpecialist referralReferral for high risk evaluationReferral for excisional biopsyReferral for excisional biopsymammogrammrinoyesbi-rads 3bi-rads 4 or 5bi-rads 6biopsymalignantatypicalindeterminatediscordantnegative

Semi-Structured Logic Statements

Inclusions

None.

Exclusions

None.

Events

NameDescription
Latest screening test type?
Most recent resulted test of either 'Last mammography' OR 'Last MRI' OR 'Last biopsy'
Actionable BI-RADS?
BI-RADS score in most recent resulted test of either 'Last mammography result' OR 'Last MRI result' is NOT 1 or 2
BI-RADS score?
BI-RADS score in most recent resulted test of either 'Last mammography result' OR 'Last MRI result'
Pathology result?
Result of pathology of last breast tissue biopsy.
malignant if 'Last biopsy' result is 'Biopsy result malignant'
OR
atypical if 'Last biopsy' result is 'Biopsy result atypical'
OR
indeterminate if 'Last biopsy' result is 'Biopsy result indeterminate'
OR
discordant if 'Last biopsy' result is 'Biopsy result discordant'
OR
negative if 'Last biopsy' result is 'Biopsy result negative'

Actions

Update next due date
Description
Pseudocode
Next due date = 'Date of last mammography' plus 2 years OR Now if 'Last mammography' does not exist
Order interval imaging
Description
Refer to Radiology report for patient specific recommendations on follow-up imaging modality and interval
Pseudocode
Referral for biopsy
Description
Referral for biopsy, either core needle or, if recommended by Radiology, FNA or excisional
Pseudocode
ORDER for `BREAST BIOPSY PROCEDURE`
OR
REFERRAL to service type `BREAST SURGERY`
Referral for high risk evaluation
Description
Pseudocode
REFERRAL for high risk breast clinic evaluation
Referral for excisional biopsy
Description
Referral for excisional biopsy or else repeat core needle or FNA if recommended by Radiology.
Pseudocode
REFERRAL to service type `BREAST SURGERY`
OR
REFERRAL for biopsy
Referral for excisional biopsy
Description
Referral for excisional biopsy, in consultation with Radiology.
Pseudocode
REFERRAL to service type `BREAST SURGERY`
Specialist referral
Description
Referral to breast surgery or medical oncology as appropriate
Pseudocode
REFERRAL to service type `BREAST SURGERY`
OR
REFERRAL to service type `MEDICAL ONCOLOGY`

Data Elements and Terminology

Data elements are logic statements that are used throughout the semi-structured specification to enhance readibility and reduce redundancy of frequently used logic phrases.

Terminology defines sets of clinical concepts and convey the specific distinguishing characteristics of the included member concepts.

Data Elements

NameDescription
Assigned female at birth
Cisgender women and all other persons assigned female at birth (including transgender men and nonbinary persons).
Sex assigned at birth = female
OR
Sex assigned at birth missing or unknown AND administrative gender = female
OR
gender identity = transgender male
Current breast cancer
Currently diagnosed with invasive or non-invasive breast cancer without having achieved remission.
CONDITIONS include `BREAST CANCER` with status active
History of bilateral mastectomy
Past history of bilateral mastectomy or unilateral mastectomy on both sides.
CONDITIONS include `BILATERAL MASTECTOMY` OR PROCEDURES include `BILATERAL MASTECTOMY PROCEDURE`
OR
(CONDITIONS include `LEFT UNILATERAL MASTECTOMY` OR PROCEDURES include `LEFT UNILATERAL MASTECTOMY PROCEDURE`
AND
CONDITIONS include `RIGHT UNILATERAL MASTECTOMY` OR PROCEDURES include `RIGHT UNILATERAL MASTECTOMY PROCEDURE`
Breast symptoms
Patient reported symptoms concerning for breast disease.
REVIEW OF SYMPTOMS include `BREAST-RELATED SIGNS OR SYMPTOMS`
Breast exam findings
Physical exam findings concerning for breast disease.
PHYSICAL EXAM OBSERVATIONS include `BREAST-RELATED SIGNS OR SYMPTOMS`
Patient eligible for screening
Patient determined to be eligible for screening.
See 'Screening Eligible' flow logic
Genetic marker or syndrome associated with a high risk of breast cancer
Genetic marker or syndrome associated with a high risk of breast cancer (e.g., BRCA1 or BRCA2 genetic variation).
CONDITIONS include `GENETIC SUSCEPTIBILITY FOR BREAST CANCER` with status active
OR
Structured documentation of `GENETIC MARKER OR SYNDROME`
Genetic marker or syndrome associated with a high risk of breast cancer as defined by ACS
ACS defined genetic marker or syndrome associated with a high risk of breast cancer, including BRCA1 or BRCA2, Li-Fraumeni syndrome (TP53 gene), Cowden or Bannayan-Riley-Ruvalcaba syndrome (PTEN gene)
CONDITIONS include `BRCA-1 MUTATION CONDITION`
OR
CONDITIONS include `BRCA-2 MUTATION CONDITION`
OR
CONDITIONS include `LI-FRAUMENI SYNDROME`
OR
CONDITIONS include `COWDEN SYNDROME`
OR
CONDITIONS include `BANNAYAN-RILEY-RUVALCABA SYNDROME`
Untested first-degree relative of BRCA carrier
First-degree relative of BRCA carrier, but untested
FAMILY HISTORY of brca1 or brca2 in first degree relative, including parent or child
First-degree relative of Li-Fraumeni syndrome, Cowden or Bannayan-Riley-Ruvalcaba syndrome
First degree relative with Li-Fraumeni syndrome (TP53 gene), Cowden or Bannayan-Riley-Ruvalcaba syndrome (PTEN gene)
FAMILY HISTORY of Li-Fraumeni syndrome, Cowden or Bannayan-Riley-Ruvalcaba syndrome in first degree relative, including parent or child
History of high-dose radiation therapy to the chest
History of high-dose radiation therapy to the chest at a young age.
CONDITIONS include `CHEST RADIOTHERAPY` with age of onset <= 30 years
Previous breast cancer
Past history of invasive or non-invasive breast cancer, with remission.
CONDITIONS include `BREAST CANCER` with status inactive, resolved, remission
OR
CONDITIONS include `PREVIOUS BREAST CANCER` with status active
High-risk benign breast lesion on previous biopsies
Past high-risk benign histology on breast biopsy at any time. Includes Atypical ductal hyperplasia (ADH) and lobular neoplasia (lobular carcinoma in situ [LCIS]/atypical lobular hyperplasia [ALH]).
CONDITIONS or DIAGNOSIS CODES include `ATYPICAL HYPERPLASIA`, `ATYPICAL DUCTAL HYPERPLASIA`, `ATYPICAL LOBULAR HYPERPLASIA`, `LOBULAR CARCINOMA IN SITU`
OR
PATHOLOGY REPORT of type `BREAST BIOPSY` includes narrative documentation of pre-malignant or high-risk lesions
Lifetime risk of breast cancer > 20% or 25%
Have a lifetime risk of breast cancer of about 20% to 25% or greater, according to risk assessment tools that are based mainly on family history
Risk assessment using a formal risk assessment tool based mainly on family history is >20% lifetime risk
OR
Risk assessment without using a formal tool is estimated >20% lifetime risk
BI-RADS breast density category C or D
Heterogeneously or extremely dense breast on mammography
BI-RADS breast density category of 'Last mammography', as reported in DIAGNOSTIC REPORT or documented in a structured form
Indicators of reduced life expectancy
Criteria that may indicate reduced life expectancy.
Patient receiving Hospice Services
Hospice services used by patient during the measurement period.
CONDITIONS or ENCOUNTER DIAGNOSES include codes from `HOSPICE INTERVENTION` OR `HOSPICE ENCOUNTER`
Patient receiving Palliative Care Services
Palliative care services used by patient during the measurement period.
CONDITIONS or ENCOUNTER DIAGNOSES include codes from `PALLIATIVE INTERVENTION` OR `PALLIATIVE ENCOUNTER`
Patient age 66 or older in Institutional Special Needs Plans or residing in long-term care facility
Patients age 66 or older in Institutional Special Needs Plans (SNP) or residing in long term care with POS code 32, 33, 34, 54, or 56 for more than 90 consecutive days during the measurement period.
AGE >= 66 years
AND
ENCOUNTER DIAGNOSES with POS code 32, 33, 34, 54 or 56 for more than 90 consecutive days
Patient with Frailty AND Medication for Dementia
Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period AND a dispensed medication for dementia during the measurement period or the year prior to the measurement period.
AGE >= 66 years
AND
>= 1 ENCOUNTER DIAGNOSES include `CODES TO IDENTIFY FRAILTY`
AND
>= 1 MEDICATIONS include `DEMENTIA EXCLUSION MEDICATIONS` with dispense
Patient with Frailty AND Advanced Illness
Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period AND either one acute inpatient encounter with a diagnosis of advanced illness or two outpatient, observation, ED or nonacute inpatient encounters on different dates of service with an advanced illness diagnosis during the measurement period or the year prior to the measurement period.
AGE >= 66 years
AND
>= 1 ENCOUNTER DIAGNOSES include `CODES TO IDENTIFY FRAILTY`
AND
(>= 1 ENCOUNTER of type acute inpatient where DIAGNOSES include `CODES TO IDENTIFY ADVANCED ILLNESS` OR >= 2 ENCOUNTERS of type outpatient, observation, ED or nonacute inpatient where DIAGNOSES include `CODES TO IDENTIFY ADVANCED ILLNESS`)
Last mammography
Latest mammography, screening or diagnostic, including film, digital or digital breast tomosynthesis (3D) mammography. Can be determined from presence of radiology report or result documented in a structured form.
Latest DIAGNOSTIC REPORT of type `SCREENING MAMMOGRAPHY` OR `DIAGNOSTIC MAMMOGRAPHY`
OR
Documented result of latest `SCREENING MAMMOGRAPHY` OR `DIAGNOSTIC MAMMOGRAPHY`.
Date of last mammography
Date of latest mammography.
Study date of 'Last mammography'
Last mammography result
BI-RADS score of 'Last mammography', as reported in DIAGNOSTIC REPORT or documented in a structured form
Pending mammography
Patient has an active mammography order or referral.
Most recent ORDER or REFERRAL with exam code `SCREENING MAMMOGRAPHY` AND status is active
Last MRI
Latest MRI, screening or diagnostic. Can be determined from presence of radiology report or result documented in a structured form.
Latest DIAGNOSTIC REPORT of type `SCREENING MRI`
OR
Documented result of latest `SCREENING MRI` as BI-RADS score.
Date of last MRI
Date of latest MRI.
Study date of 'Last MRI'
Last MRI result
BI-RADS score of 'Last MRI', as reported in DIAGNOSTIC REPORT or documented in a structured form
Pending MRI
Patient has an active MRI order or referral.
Most recent ORDER or REFERRAL with exam code `SCREENING MRI` AND status is active
Last ultrasound
Latest US, screening or diagnostic. Can be determined from presence of radiology report or result documented in a structured form.
Latest DIAGNOSTIC REPORT of type `SCREENING US` OR `DIAGNOSTIC US`
OR
Documented result of latest `SCREENING US` OR `DIAGNOSTIC US` as BI-RADS score.
Date of last ultrasound
Date of latest ultrasound.
Study date of 'Last ultrasound'
Pending ultrasound
Patient has an active MRI order or referral.
Most recent ORDER or REFERRAL with exam code `SCREENING US` AND status is active
Last biopsy
Latest breast biopsy. Can be determined from presence of pathology report or result documented in a structured form.
Latest DIAGNOSTIC REPORT of type `BREAST BIOPSY`
OR
Documented result of latest `BREAST BIOPSY` as diagnostic code.
Date of last biopsy
Date of latest biopsy.
Study date of 'Last biopsy'
Pending biopsy
Patient has an active biopsy order or referral.
Most recent ORDER or REFERRAL where exam code is `BREAST BIOPSY PROCEDURE` AND status is active
Biopsy result negative
Pathology of breast biopsy has no atypical hyperplasia, LCIS or malignant findings and is not indeterminate or discordant. May have other benign breast conditions.
Biopsy result atypical
Pathology of breast biopsy has atypical findings.
Biopsy result indeterminate
Pathology of breast biopsy has indeterminate findings.
Biopsy result is `INDETERMINATE HISTOLOGY`
Biopsy result discordant
Pathology of breast biopsy has findings discordant with imaging result.
Biopsy result is 'Biopsy result negative' AND 'Last mammography result' is BI-RADS 5
Biopsy result malignant
Pathology of breast biopsy has malignant findings.
Biopsy result includes `INVASIVE BREAST CANCER` OR `NON-INVASIVE BREAST CANCER`
BRCA-1 mutation test
BRCA-1 mutation diagnostic test, including pathology report
EXISTS DIAGNOSTIC TEST with type `BRCA-1 MUTATION`
BRCA-2 mutation test
BRCA-2 mutation diagnostic test, including pathology report
EXISTS DIAGNOSTIC TEST with type `BRCA-2 MUTATION`
BRCA-1 mutation diagnosis
Known BRCA-1 mutation carrier.
CONDITIONS include `BRCA-1 MUTATION CONDITION` with status active
BRCA-2 mutation diagnosis
Known BRCA-2 mutation carrier.
CONDITIONS include `BRCA-2 MUTATION CONDITION` with status active
Family history of known BRCA1/2 mutation
Family member with known BRCA mutation of any type.
FAMILY HISTORY includes family member with DIAGNOSIS `BRCA-1 MUTATION CONDITION` OR `BRCA-2 MUTATION CONDITION`
Family history of breast cancer
Family history of breast cancer.
FAMILY HISTORY includes family member with DIAGNOSIS `INVASIVE BREAST CANCER`
OR
FAMILY HISTORY includes family member with DIAGNOSIS `NON-INVASIVE BREAST CANCER`
Family history of ovarian cancer
Family history of ovarian cancer.
FAMILY HISTORY includes family member with DIAGNOSIS `OVARIAN CANCER`
Family history of tubal cancer
Family history of tubal cancer.
FAMILY HISTORY includes family member with DIAGNOSIS `TUBAL CANCER`
Family history of peritoneal cancer
Family history of peritoneal cancer.
FAMILY HISTORY includes family member with DIAGNOSIS `PERITONEAL CANCER`
'Compelling family history of breast cancer' is true
Pedigree of blood relatives on maternal and/or paternal side includes compelling history of breast cancer.
Output of validated brief familial risk assessment tool is positive
OR
'Informal familial risk criteria' exist
Informal familial risk criteria
Criteria in first- or second-degree blood relatives known to be associated with increased risk of inherited breast cancer susceptibility variant. May include criteria such as:
2 or more relatives with breast or ovarian cancer
breast cancer occurring before age 50 years
a family history of both breast and ovarian cancer
one or more relatives with 2 cancers (breast and ovarian cancer or 2 independent breast cancers)
male relatives with breast cancer
Source: ACS
FAMILY HISTORY includes >= 2 first- or second- degree relatives with breast cancer
OR
FAMILY HISTORY includes >= 2 first- or second- degree relatives with ovarian cancer
OR
FAMILY HISTORY includes >= 1 first- or second- degree relatives with breast cancer diagnosed <= 50 years old
OR
FAMILY HISTORY includes at least one first- or second- degree relative with breast AND at least one relative wth ovarian cancer
OR
FAMILY HISTORY includes >= 1 first- or second- degree relative with both breast and ovarian cancer
OR
FAMILY HISTORY includes >= 1 first- or second- degree relative with 2 independent breast cancers
OR
FAMILY HISTORY includes >= 1 first- or second- degree male relative with breast cancer

Terminology

Terminology defines sets of clinical concepts and convey the specific distinguishing characteristics of the included member concepts.

  • Clinical Focus - A statement describing the general focus of the set, including a description of the intended constituent concepts. This can include information about clinical relevancy or a statement about the general focus of the set.
  • Inclusions - A statement that describes what specific concept or code criteria are included and why.
  • Exclusions - A statement that describes what specific concept or code criteria would normally be included, but are specifically excluded by the authors, including their rationale for exclusions.

Content

BREAST CANCER
Clinical Focus
Diagnosis or billing codes for invasive breast cancer
Inclusions
Invasive and non-invasive forms of breast cancer.
Exclusions
Cancers affecting skin of breast, Paget's disease.
BILATERAL MASTECTOMY
Clinical Focus
Diagnosis codes for history of bilateral mastectomy
Inclusions
Exclusions
UNILATERAL MASTECTOMY
Clinical Focus
Diagnosis codes for history of unilateral mastectomy with unspecifed laterality.
Inclusions
Unspecified laterality
Exclusions
Specified laterality
LEFT UNILATERAL MASTECTOMY
Clinical Focus
Diagnosis codes for history of left unilateral mastectomy
Inclusions
Exclusions
Unspecified laterality
RIGHT UNILATERAL MASTECTOMY
Clinical Focus
Diagnosis codes for history of right unilateral mastectomy
Inclusions
Exclusions
Unspecified laterality
BILATERAL MASTECTOMY PROCEDURE
Clinical Focus
Procedure codes for bilateral mastectomy
Inclusions
Exclusions
LEFT UNILATERAL MASTECTOMY PROCEDURE
Clinical Focus
Procedure codes for left unilateral mastectomy
Inclusions
Exclusions
Unspecified laterality
RIGHT UNILATERAL MASTECTOMY PROCEDURE
Clinical Focus
Procedure codes for right unilateral mastectomy
Inclusions
Exclusions
Unspecified laterality
CHEST RADIOTHERAPY
Clinical Focus
History of radiation to chest
Inclusions
Exclusions
ATYPICAL HYPERPLASIA
Clinical Focus
Diagnosis codes for past atypical hyperplasia on tissue biopsy
Inclusions
ADH and ALH
Exclusions
ATYPICAL DUCTAL HYPERPLASIA
Clinical Focus
Diagnosis codes for past atypical ductal hyperplasia on tissue biopsy
Inclusions
Exclusions
ATYPICAL LOBULAR HYPERPLASIA
Clinical Focus
Diagnosis codes for past atypical lobular hyperplasia on tissue biopsy
Inclusions
Exclusions
LOBULAR CARCINOMA IN SITU
Clinical Focus
Diagnosis codes for past LCIS on tissue biopsy
Inclusions
Exclusions
HOSPICE INTERVENTION
Clinical Focus
Codes from HEDIS measure denominator exclusions
Inclusions
Exclusions
HOSPICE ENCOUNTER
Clinical Focus
Codes from HEDIS measure denominator exclusions
Inclusions
Exclusions
PALLIATIVE INTERVENTION
Clinical Focus
Codes from HEDIS measure denominator exclusions
Inclusions
Exclusions
PALLIATIVE ENCOUNTER
Clinical Focus
Codes from HEDIS measure denominator exclusions
Inclusions
Exclusions
CODES TO IDENTIFY FRAILTY
Clinical Focus
Codes from HEDIS measure denominator exclusions
Inclusions
Exclusions
DEMENTIA EXCLUSION MEDICATIONS
Clinical Focus
Codes from HEDIS measure denominator exclusions
Inclusions
Exclusions
CODES TO IDENTIFY ADVANCED ILLNESS
Clinical Focus
Codes from HEDIS measure denominator exclusions
Inclusions
Exclusions
SCREENING MAMMOGRAPHY
Clinical Focus
Mammogram intended for routine screening purposes
Inclusions
Film, digital or digital breast tomosynthesis (3D) mammography
Exclusions
Diagnostic mammography
DIAGNOSTIC MAMMOGRAPHY
Clinical Focus
Mammogram intended for diagnostic purposes
Inclusions
Film, digital or digital breast tomosynthesis (3D) mammography
Exclusions
Screening mammography
SCREENING MRI
Clinical Focus
Breast MRI intended for routine screening purposes
Inclusions
Exclusions
Diagnostic breast MRI
SCREENING ULTRASOUND
Clinical Focus
Breast ultrasound intended for routine screening purposes
Inclusions
Exclusions
Diagnostic breast ultrasound
DIAGNOSTIC ULTRASOUND
Clinical Focus
Breast ultrasound intended for diagnostic purposes
Inclusions
Exclusions
Screening breast ultrasound
BREAST SURGERY
Clinical Focus
Specialty codes for breast surgery
Inclusions
Exclusions
MEDICAL ONCOLOGY
Clinical Focus
Specialty codes for medical oncology
Inclusions
Exclusions
BREAST-RELATED SIGNS OR SYMPTOMS
Clinical Focus
Breast signs or symptoms which could be indicative of breast cancer.
Inclusions
Palpable signs, such as a breast mass, asymmetric thickening/nodularity, asymmetric breast enlargement, or change in shape/contour.
Skin changes (e.g. peau d'orange, erythema, nipple excoriation, scaling, eczema, skin ulcers)
Breast pain
Nipple inversion, retraction, or discharge
Axillary mass
Exclusions
BRCA-1 MUTATION
Clinical Focus
Lab codes for BRCA-1 mutation diagnostic testing.
Inclusions
Pathology reports
Exclusions
BRCA-2 MUTATION
Clinical Focus
Lab codes for BRCA-2 mutation diagnostic testing.
Inclusions
Pathology reports
Exclusions
BRCA-1 MUTATION CONDITION
Clinical Focus
Condition codes for BRCA-1 mutation carrier.
Inclusions
Exclusions
BRCA-2 MUTATION CONDITION
Clinical Focus
Condition codes for BRCA-2 mutation carrier.
Inclusions
Exclusions
GENETIC MARKER OR SYNDROME
Clinical Focus
Condition codes for genetic marker or syndrome associated with a high risk of breast cancer (e.g., BRCA1 or BRCA2 genetic variation).
Inclusions
Exclusions
GENETIC SUSCEPTIBILITY FOR BREAST CANCER
Clinical Focus
Condition codes for genetic marker or syndrome associated with a high risk of breast cancer (eg, BRCA1 or BRCA2 genetic variation).
Inclusions
Exclusions
LI-FRAUMENI SYNDROME
Clinical Focus
Condition codes for Li-Fraumeni syndrome (TP53 gene)
Inclusions
Exclusions
COWDEN SYNDROME
Clinical Focus
Condition codes for Cowden syndrome
Inclusions
Exclusions
BANNAYAN-RILEY-RUVALCABA SYNDROME
Clinical Focus
Condition codes for Bannayan-Riley-Ruvalcaba syndrome (PTEN gene)
Inclusions
Exclusions
OVARIAN CANCER
Clinical Focus
Condition codes for ovarian cancer.
Inclusions
Exclusions
TUBAL CANCER
Clinical Focus
Condition codes for tubal cancer.
Inclusions
Exclusions
PERITONEAL CANCER
Clinical Focus
Condition codes for peritoneal cancer.
Inclusions
Exclusions
BREAST BIOPSY PROCEDURE
Clinical Focus
Procedure codes for breast tissue biopsy
Inclusions
Excisional, core, and aspiration (FNA)
Exclusions
BREAST BIOPSY
Clinical Focus
Report type codes for breast tissue biopsy
Inclusions
Excisional, core, and aspiration (FNA)
Exclusions
INDETERMINATE HISTOLOGY
Clinical Focus
Diagnosis codes for breast tissue biopsy indeterminate results.
Inclusions
Exclusions