Site Specific Cancer Risk, Screening, and Early Detection Guidelines PDF

TABLE 5 SITE SPECIFIC CANCER RISK,SCREENING,AND EARLY DETECTION GUIDELINES SITE ASSOCIATED RISK SIGNS AND SCREENING AND FACTOR SYMPTOMS DETECTION BILIARY Older Americans (60 Pruritus Physica...

TABLE 5 SITE SPECIFIC CANCER RISK,SCREENING,AND EARLY DETECTION GUIDELINES SITE ASSOCIATED RISK SIGNS AND SCREENING AND FACTOR SYMPTOMS DETECTION BILIARY Older Americans (60 Pruritus Physical examination TRACT to 70) Jaundice Ultrasound Female predominance Abdominal pain White women Nausea and vomiting Chronic infection with Fever livers Malaise parasites(Clonorchis Enlarged liver sinensis) Palpable mass in Eating raw or pickled upper right quadrant freshwater fish from Lower extremely Southeast Asia edema ascites Bladder Occupational Microscopic or gross Urinalysis exposure hematuria Urine cytology (textiles, rubbers) Dysuria Physical examination Cigarette smoking Bladder irritability Cytoscopy Chronic bladder Urinary infection urgency,frequency,a nd hesitancy Brain Environmental Persistent Physical examination exposures (vinyl generalized Prompt follow –up with chlorides) headache onset of signs and Epstein-Barr virus) Vomiting symptoms. Seizures Loss of fine motor Control Unsteady gait change in personality lethargy slurring of speech loss of memory impaired vision Breast Previous history of Painless mass or Consist of three cancer thickening in the modalities: Obesity breast or axilla 1. breast self High fat intake Skin dimpling, awareness Family history of puckering, or nipple 2. clinical examination breast cancer retraction ages 20-40;every 3  Exposure to ionizing Nipple discharge or years,over 40 every radiation before age scaliness year. 35 Edema (peau d Early menarche ‘orange) 3. Annual Nulliparity Erythema, mammography,over First pregnancy after ulceration 40. age 30 Change in size, Baseline mammogram contour or shape of at age 25 breast recommended for genetically predisposed women. Ultrasound MRI Image guided fine- needle aspiration or core needle biopsy Genetic Counselling BRCA genes Cervix Early age at first Abnormal vaginal Papanicolau (Pap test) intercourse (before bleeding Pelvic examination age 20) Persistent postcoital Colposcopy Multiple sex partners spotting Smoking Human papilloma virus Herpes simplex virus type 2 Colon and Colorectal polyps Depend on location Digital rectal rectum Diet high in fat of tumor examination(DRE)ann Diets low in fiber Right colon ually after age 40 Genetic component Anemia Stool occult blood Familial Gastrointestin testing annually from polyposis al bleeding age 50 Gardner’s Persistent Flexible syndrome lower sigmoidoscopy Peutz-jeghers abdominal Double-contrast syndrome pain barium enema Inflammatory Right lower Colonoscopy bowel disease quadrant Crohn’s mass disease Left colon Ulcerative Gross blood in colitis stool  Decrease in stool calibre Change in bowel habits, constipation, diarrhea Rectum Hematochezia Tenesmus Feeling of incomplete evacuation Rectal pain (late sign) Prolapsed of tumor Esophagus Men 50-70 years old Early Double -contrast Nitrosamines and Dysphagia barium swallow ethanol consumption Weight loss Esophagoscopy with Cigarette smoking Regurgitation staining techniques Precancerous lesions Aspiration Brush biopsy Achalasia (failure of Odynophagia Radioisotopes in tumor lower esophagus to (pain on scanning relax with swallowing) swallowing) Combined smoking Gastroesopha and drinking geal reflux Barrett’s esophagus Advanced (chronic gastric reflux) Left supraclavicula r adenopathy Chronic cough Choking after eating Massive hemoptysis Hematemesis hoarseness Leukemia Acute Low grade fever Complete blood count Men at higher risk than Anemia,pallor Platelet count women Lymphadenopathy Physical examination Whites at high risk Generalized than African weakness Americans Frequent infections Exposure to radiation Easy bruising  Exposure to toxic Bleeding (nose organic chemicals ,gums) (benzene),drugs(alkal Petechia on lower yting extremeties agents,chloramphenic Bone and joint pain ol) Chronic Benzene exposure Lymphadenopathy High-dose radiation Splenomegaly Philadelphia Weight loss chromosome Night sweats Malaise, weakness Recurrent infections,fever Early satiety Liver Exposure to aflatoxin Early Annual physical Environmental Bloating examination exposures Abdominal Awareness of risk Viral hepatitis pain factors More frequent in Fever Ultrasound males Weight loss Computer tomography Alcoholic cirrhosis Decreased scan Parasitic infestation appetite Magnetic resonance Chronic venous Nausea imaging obstruction Advanced Paraneoplastic syndromes Jaundice Anabolic steroid use Ascites Extreme weight loss anorexia Lung Cigarette smoking Nagging cough Chest Xray (active, passive) Dull ache in the chest CT scan Increase in age Recurrent or PET scan Asbestos persistent upper Occupational respiratory infection exposure among Wheezing miners Dyspnea Air pollution Hemoptysis Change in volume,color,and odor of sputum. Lymphoma Hodgkin’s Persistent swelling or Physical examination Epstein-Barr painless lymph Complete blood count virus nodes (neck, axilla)  Higher socio- Recurrent fevers economic Night sweats status Weight loss Small family Pruritus Cough, shortness of breath Non- Leukocytosis Hodgkins Lymphadenopathy Occupational Fatigue exposure Fever (flour and Chills agricultural Night sweats industries) Decreased appetite Abnormalities weight loss of immune system HIV Exposure to radiation or chemotherap y Ovary Familial predisposition Early Pelvic ultrasonography Late menopause Vague abdominal (with vaginal probe) Nulliparity discomfort Elevated serum First pregnancy at age Dyspepsia markers 30 Flatulence Carcinoembryonic Bloating antigen (CEA) Digestive CA-125 antigen disturbance Genetic testing BRCA Advanced genes Abdominal distention Pain Abdominal and pelvic masses Ascites Lower extremity edema Pancreas Older men Early Blood glucose level Smoking Hypoglycaemia Physical examination Chronic pancreatitis Weight loss, Abdominal ultrasound Ethanol consumption anorexia Abdominal CT c/FNA Abdominal pain Endoscopic retrograde  Cramping pain Cholangiopancreatogr associated with aphy diarrhea Pruritus Advanced Jaundice Ascites Lower extremity edema Prostate Occupational Early DRE exposure Difficult starting Prostate specific Cadmium,heavy urinary stream antigen (PSA) metals,chemicals Unexplained cystitis Biochemical markers Age median age of Urinary bleeding Transrectal ultrasound incidence,70 years Dribbling (TRUS) Bladder retention Advanced Bladder outlet obstruction Urinary retention Ureteral obstruction with anuria Azotemia Uremia Anorexia Hematuria Bone pain Skin Fair skinned,freckels Changes in wart or Extensive skin (nonmelano Blonde hair,blue eyes mole examination ma) Sun exposure Sore that does not Mole mapping Severe sunburn in heal childhood ABCD’s of Skin Familial conditions Cancer Previous skin cancers A-assymetry (change History of dysplastic in size and shape) nevi B-border irregularity C-color (change in color) D-diameter (>than 6 mm) Stomach Dietary carcinogens Feeling of fullness Occult blood testing (smoked,salt-cured Weight loss Complete blood count and charcoal cooked Loss of appetite Endoscopy foods)  Familial,genetic Anemia (iron disposition deficiency) Person with type A Malaise blood (15 to 20% Complaints of increase incidence) indigestion Benign gastric ulcers Gastrointestinal Tobacco bleeding alcohol Abdominal pain Persistent epigastric distress Testis Cryptorchid testes Early Testicular self- Young white men rate Painless mass examination (monthly) 4 times that of African Gynecomastia beginning in Americans Heavy sensation in adolescence scrotum Testicular ultrasound Advanced Ureteral obstruction Abdominal mass Pulmonary symptoms Elevated human chorionic gonadotrophin Vulva Postmenopausal Lump or ulcer Visual and manual History of genital warts Itching pain inspection of external Human papillomavirus Burning genetalia Other sexually Bleeding Colposcopic exam transmitted diseases Discharge Vulvar biopsy Lower socioeconomic status Multiple sex partners Precancerous or cancerous lesions of cervix Cancer Diagnosis and Staging Tumor Markers PROSTATE-SPECIFIC ANTIGEN (PSA) can be elevated in prostate cancer. However,PSA levels can also be elevated in the presence of benign prostatic hyperplasia,in older men,and in men with larger prostate glands.When screening for prostate cancer,the PSA should be accompanied by a Digital Rectal Examination (DRE).The PSA test is also useful in evaluating response to treatment and recurrence in patients treated with surgery or radiation therapy. If the PSA level was elevated at diagnosis,it shoud fall towards normal levels after definitive treatment. A rising PSA level would suggest recurrence of the disease. S-100 S-100 is found in melanoma cells.This protein is measured in tissue samples of suspected melanomas.It is usually elevated in patients with metastatic melanoma. THYROGLOBULIN Thyroglobulin is a protein made by the thyroid gland. Measured in the blood, it is elevated in many thyroid diseases, including some forms of thyroid cancer. Treatment may include removal of the entire gland, with or without radiation therapy. Afterward, thyroglobulin should fall into undetectable levels.A rise in thyroglobulin levels indicates cancer recurrence. ESTROGEN and PROGESTERONE RECEPTOR Breast cancer tissue has been tested for the presence of estrogen and progesterone receptors.These markers provide an indication of the aggressiveness of the cancer and how likely the cancer will be to respond to specific types of endocrine therapy. CA 15-3 and CA 27-29 Specific for breast cancer,these markers are found in the blood of affected patients and are most useful in evaluating the effectiveness of treatment for individuals with advanced disease. Both tests are commonly used to monitor for recurrence in women who have been treated for breast cancer.The CA27-29 test maybe more sensitive than the CA 15- 3. CARCINOEMBYONIC ANTIGEN (CEA) AND CA 19-9 Elevated in advanced colorectal cancer.It has been considered the “gold standard” tumor marker for colorectal cancer for over 20 years.An elevated CEA level before surgical intervention for colorectal cancer may indicate a poorer prognosis.It can also be elevated in other forms of cancer including breast,lung,thyroid,pancreas,liver,stomach ovary and bladder. CA-125 Of women with advanced epithelial ovarian cancer,the most common form of ovarian cancer,90% will have an elevated CA-125 level. Women with a strong family history of ovarian cancer are often screened with both CA-125 testing and ultrasound.Because of its elevation in other malignancies and conditions, it is not recommended that CA-125 level alone be the determining tool in diagnosing ovarian cancer. HUMAN CHORIONIC GONADOTROPIN (HCG) AND ALPHA-FETOPROTEIN (AFP) Female patients with germ cell ovarian tumors and men with nonseminomatous testicular cancer often display elevated levels of HCG and AFP.There is no positive correlation between the level of the marker concentration and prognosis.AFP levels are higher than normal in 2/3 of patients with cancer.The level increases proportionately to the size of the tumor.AFP levels may also be elevated in chronic hepatitis. BETA-2 MICROGLOBULIN (B2M) Elevated in persons with multiple myeloma,chronic lymphocytic leukemia,and some lymphomas,as well as some kidney disease. HER-2/neu Overexpressed or elevated in one third of person diagnosed with breast cancer.It is used to predict response to therapy.Individuals who express this feature respond to a specific type of monoclonal antibody aimed against the HER-2/neu receptor on breast cancer cells. CHROMOGRANIN A (Cga) This is produced by neuroendocrine tumors including carcinoid,neuroblastoma,and small cell lung cancers.It is the most sensitive tumor markers for carcinoid tumors. DIAGNOSTIC IMAGING METHODS The role of imaging is an important in the diagnosis and staging of cancer. X-RAY Radiographic studies allow visualization of internal structures of the body and permit the distinction to be made between normal and abnormal structure and function.X-ray examination may be specific or may view the dynamic function of the organ system. MAMMOGRAPHY Is an X-ray study used to screen for malignancies of the breast.It is approximately 80 to 85% in detecting breast cancer,but is limited in detecting abnormalities in dense breast tissue.Mammography is very useful as a screening tool because of its ability to detect non-palpable breast masses.To be effective,mammography should be accompanied and correlated with clinical findings. Full-fields digital mammography and computer-aided detection are newer mammography imaging techniques,offering the advantages in and improving visualization of suspicious areas during the actual procedures. COMPUTED TOMOGRAPHY (CT) It uses special x-ray equipment to obtain images from a variety of angles through the body and then employs computer processing to reproduce a detailed cross-sectional image of tissues and organs.CT imaging can be performed with clarity in a wide range of tissue types including lung,bone,soft tissue,and blood vessels.It is usually the preferred method for diagnosis of liver,lung and pancreatic cancers. The image obtained allows the clinician to confirm the presence and precise location of a tumor.This technique measures tumor size and involvement or spread into the adjacent areas. CT examination often requires the use of varied contrast materials to enhance the visibility of certain tissues or blood vessels.The contrast materials can be swallowed,injected into blood stream,or administered via enema.It is important to elicit allergy history,diagnoses of diabetes,heart,or kidney disease. MAGNETIC RESONANCE IMAGING (MRI) This does not use ionizing radiation to provide images.This technology is based on the interaction of atomic nuclei and radiowave placed in a strong magnetic field.The images produced represent intensities of these electromagnetic signals from the hydrogen nuclei in the patient.The technique is based on the premise that abnormal tissue has more free water and will display different characteristics.MRI is the preferred imaging,vascular imaging,and avascular necrosis.patients are not exposed to radiation with this imaging technique.A number of contrast agents are used,depending upon the target of interest. ULTRASOUND Uses a set of reflections of high frequency sound waves from internal tissues of the body that have been focused for viewing it.It is non-invasive,uses no ionizing radiation that can be used through out the body.There are a wide variety of high resolution probes and transducers that have been developed over the years that offer improved accuracy and ease of noninvasive diagnosis.Deep vein thrombosis is now easily identified with color- flow Doppler imaging. NUCLEAR MEDICINE Nuclear medicine imaging techniques are based on the principle of tagging a physiologic substance in the body and measuring its flow,distribution,or presence in the target organ or system.A radiopharmaceutical agent is injected into the patient,and the radioactive decay events are captured by gamma or PET camera.More radiopharmaceutical agents produces an image of the metabolic process.This technique is excellent for evaluating various metabolic and physiologic changes. POSITRON EMISSION TOMOGRAPHY (PET) PET uses radioactive positively charged particles to detect subtle changes in the body’s metabolism and chemical activities.The radiopharmaceutical agent (radiotracer) most commonly used and approved by the U.S Food and Drug Administration (FDA) is F- fluorodeoxyglucose (F-FDG).based on the premise that malignant tumors use glucose and grow at a faster rate than healthy tissue,the PET scan locates areas of high F_FDG uptake.False positive results can occur,because inflammation and infection also increases F-FDG uptake and can mimic a positive malignant tumor finding. POSITRON EMISSION TOMOGRAPHY WITH COMPUTED TOMOGRAPHY (PET-CT) PET-CT is the fusion of these two imaging modalities,which results in significantly improved diagnostic accuracy.There is more accurate anatomic localization of PET findings,resulting in fewer false-positive PET interpretations. LYMPHOSCINTIGRAPHY Is a nuclear medicine imaging technique that utilizes radiolabeled monoclonal antibodies to visualize microscopic sites of metastasis or suspected malignancy.A monoclonal antibody against a specific tumor antigen is combined with tracer amount of radioactive substance and injected either into tissue or intravenously.The activity and location of the site where the substance migrates can then be imaged with the use of scanner or probe.This provides a guide for the surgeon to the target of interest to more accurately remove any diseased tissue.It is used in the diagnosis and staging of malignant melanoma and breast cancer. STAGING is the process of describing the extent or spread of a disease from its site of origin.This information is important in determining the choice of therapy,monitoring response to treatment,and assessing prognosis. 3 Types of Staging 1. Surgical staging-uses invasive surgical techniques to actually visualize structures and assess the extent of the disease. 2. Clinical staging -is based on professional judgement and measurement of the primary tumor’s size,location in the body,and the evidence of disease through physical examination. 3. Pathologic staging-is the practice of examination of the tissue of interest both grossly and microscopically to evaluate its characteristics and make an assessment as to the aggressiveness of the malignant tumor. There are variety of different staging systems utilized today.The most commonly known staging system for solid tumors is the Tumor-node-metastasis (TNM) system. (T) which assess tumors based on the size or extent of primary tumor (N) assesses the absence or presence of regional lymph node involvement, and (M) assesses the absence or presence of distant metastasis. Once ascertained, a stage is designated and typically ranges from stage I to IV. STAGE DESCRIPTION STAGE 0 Carcinoma in situ (Tis-N0-M0) STAGE I Tumor of under 2 cm w ith negative nodes (T1-N0-M0)(includes microinvasive T1,less than 0.1 cm) STAGE IIA Tumor of 1 to 2 cm with positive nodes (including micrometastasis N1,/or less than 2 mm), or 2 to 5 cm with negative nodes (T)-N1,T1- N1,T2-N0, All MO STAGE IIB Tumor of 2 to 5 cm with positive nodes or (T2-N1,MO) greater than 5 cm with negative nodes T3-N0, MO) STAGE III A No evidence of primary tumor or tumor of less than 2 cm with involved fixed lymph nodes, or tumor greater than 5 cm with involved movable or nonmovable nodes. (T0-N2,T1-N2,T2-N2,T3-N1, T3-N2,All M0)  STAGE IIIB Tumor of any size with direct extension to chest wall or skin,with or without involved lymph nodes,or any size tumor with involved internal mammary lymph nodes (T4-any N,any T-N3,all MO) STAGE IV Any distant metastasis (include ipselateral supraclavicular nodes) CANCER OF THE BRAIN and CENTRAL NERVOUS SYSTEM Epidemiology Malignant and non malignant brain tumors are reported in 14.8 per 100,000 individuals per year.There are approximately 44,000 new cases of primary brain tumors in the united States each year. Etiology and risk factor Ionizing radiation Electromagnetic fields and cellular phone Intake of food treated with nitrosamines 4 Most common primary brain tumors Gliomas –are most common,accounting for 42% of primary brain tumors and 78% of malignant brain tumors.It includes: 1. Acrocytomas are divided into 4 WHO grades: Grade I: Pilocytic astrocytoma Grade II: Astrocytoma Grade III: Anaplastic Astrocytoma Grade IV: Glioblastoma multiforme 2. Oligodendroglioma make up 10% of gliomas and are most often low grade,although they can also have malignant features. 3. Mixed glioma and  4. Ependymoma account for approximately 6% of gliomas ,they develop from the walls of the ventricles.Hydrocephalus is the concern of the patients.They are slow growing and outcome improves with aggressive surgical resection. Meningiomas account for 30% of primary tumors and originate from the arachnoid covering of the brain.Less than 10% of these tumors are more aggressive and are classified as atypical,malignant or anaplastic.They have higher recurrence rate and require other treatments in addition to surgical resection. Schwannomas and pituitary tumors account for 7 to 8% of pituitary tumors.They are usually benign and respond well to treatment whether surgical,medical or radiotherapuetic. Meningiomas Nerve sheath tumors Pituitary tumors CLINICAL FEATURES: 1. Increased intracranial pressure caused by blood brain barrier (BBB) disruption,with triad of symptoms: headache,nausea and vomiting and papilledema( swelling of the optic disc). 2. Cerebral edema 3. Neurologic deficit 4. Change in mental status:caused by brain shifting associated with increased ICP or with hydrocephalus caused by tumor growth. 5. Seizures occur as the presenting sign in approximately 1/3 of patients with brain tumors who have supratentorial (cerebral hemispheres) lesions. DIAGNOSIS: 1. History and physical exam 2. Blood tests 3. Computed Tomography 4. Magnetic Resonance Imaging (MRI) 5. Magnetic Resonance Angiography (MRA) MEDICAL MANAGEMENT 1. Surgery: Stereotactic biopsy- is performed to establish a diagnosis only,It is used for tumors that are deep or in eloquent areas of the brain stem where tumor resection is not feasible. Craniotomy : goals are twofolds; to obtain a diagnosis,and to remove tumor and decrease mass effect,if present.In the case of some benign tumor,complete tumor resection maybe curative. Ex: for infiltrative or malignant tumor,tumor debulking may provide symptom relief and decrease ICP before initiation of further therapy. 2. Radiation therapy: The integral part of the treatment of malignant brain tumors.It may be used alone or in combination with chemotherapy or experimental drugs.one diagnosis is established via stereotactic biopsy or craniotomy,an RT consultation takes place to assess the most appropriate type/dose of treatment.The radiation oncologist makes a recommendation based on tumor clasification,grade,location,and amount of residual tumor.Many centers withhold RT after gross total resection of low-grade tumors,such as oligodendrogliomas,and continue to evaluate with serial MRI or CT.Once there is evidence of tumor recurrence,a decision is made whether to reoperate and/or to proceed with RT. 3. Chemotherapy: Nitrosoureas,Carmostine given IV,lomustine given orally. A biodegradable chemotherapy wafera period of 3 to3 weeks can be implanted at the time of craniotomy for tumor debulking. 4. Other treatment modalities Angiogenic substances:disrupts the process of the tumor to develop new abnormal vessels and a vascular supply necessary for tumor growth. Gene therapy: uses viral vectors (retrovirus,adenovirus,or human herpes simplex virus) that are unable to replicate.They are injected into dividing tumor cells,making the tumor cells sensitive to antiretroviral drugs. Oncolytic viruses,are developed to replicate in tumor cells but not in normal cells.Once inside the cell,these viruses”infect”tumor cels,releasing proteins and interfere with tumor growth.They replicate and infect surrouding tumor cells.Adenovirus,herpes simplex virus,and others have been followed in clinical trials. Disease-Related Complications and Treatment The most common complications of brain tumors,particularly malignant tumors,include the following:  a. Increased ICP b. Seizures c. Metal status changes d. Focal neurologic signs e. Deep vein trombosis (DVT);pulmonary embolus (PE) The most common complications of brain tumor treatments include all of the above as well as the following: a. Intracranial hemorrhage b. Infection c. Treatment effect:necrosis d. Steroid myopathy e. Immunosuppression f. Cognitive sequelae BREAST CANCER The most common cancer and the leading cause of cancer deaths in women throughout the world,it is a major public health concern. EPIDEMIOLOGY: American women lifetime risk for developing invasive breast cancer is 1 and 8.This translates into 211,240 newly diagnosed female cases in the US during 2005.Men rarely develop breast cancer,by comparison,accounting for only 1690 new cases during the same year. RISK FACTOR Gender.Women are more likely than men to develop breast cancer.In US,breast cancer accounts for 32% of all invasive cancers in womn and less than 1% of the cancers in men. Age. Most breast cancer cases are diagnosed in women 40 years of age and older,but majority of casesoccur in women over age 50. Personal history of cancer. A previous history of cancer increase the risk of woman’s lifetime risk for developing a second breast cancer in the opposite breast. Family history of cancer and genetics.Women with a family history of breast cancer in one first-degree relative (mother,sister or daughter) have a relative risk of 2.1 to 4.0.  Hormonal factors. Early onset of menarche (before age 12),late menopause (at age 55 or above),and greater duration of years of regular menses are associated with increased risk of breast cancer. Having no children (nulliparity) or the first full term pregnancy after age 30 places the woman at increased risk. Benign breast disease.Encompasses a wide array of histopathologic tissue diagnoses women typically experience clinically at some time in their lives but are never biopsied.”Fibrocystic disease” is a phrase to describe clinical symptoms and findings of local or generalized lumpiness,pain or cystic changes.Nonproliferative lesions, Proliferative lesions without atypia and proliferative lesions with atypia,or typical hyperplasia are example of these. Obesity and dietary fat. Increased consumption of dietary fat increase incidence of women to the development of breast cancer. Obesity is associated with an increased risk of breast cancer in post menopausal women. Most circulating estrogen in post menopausal women is produced in fat tissue. Dietary fat intake during childhood and adolescence may influence breast cancer risk. Radiation exposure. A greater than expected incidence of breast cancer has been seen in women exposed in ionizing radiation to the chest treatment for Hodgkin’s disease. Alcohol consumption.several studies have shown an increased risk of breast cancer associated with alcohol consumption of 2 or more drinks per day.It appear to increase levels of circulating estrogens and androgens.Heavy alcohol consumption may also be associated with poor nutrition or other social and environmental factors that may affect general health,access to care,and stage at diagnosis. Other factors PREVENTION,SCREENING AND DETECTION Breast cancer is heterogenous disease;a disease of many characteristics,varying from woman to woman in its potential for development,growth and metastasis. Early detection is the most important means for control of breast cancer.The American Cancer Society (ACS) Screening Guideliens for asymptomatic women. 1. Mammography (routine screening mammography) every year beginning the age of 40. 2. CBE by a health professional every 3 years for women ages 20 to 39 and annually beginning age 40. 3. BSE monthly by all women beginning age 20.