instability. Note: Estimates are age adjusted to the 2000 US standard population. Mammography prevalence estimates do not distinguish between examinations for screening and diagnosis. Source: National Health Interview Survey, 2018. ©2019, American Cancer Society, Surveillance Research 22 Breast Cancer Facts & Figures 2019-2020 Magnetic resonance imaging (MRI) Breast MRI uses high-powered magnets along with radio waves and computers to produce an image. In 2007, the American Cancer Society published recommendations for the use of MRI for screening women at increased risk of breast cancer.188 Beginning at age 30, annual screening with MRI, in addition to mammography, is recommended for women with an estimated lifetime risk of breast cancer of at least 20%-25% due to the presence of a high-risk variation in the breast cancer susceptibility genes BRCA1 or BRCA2, a first-degree relative with a BRCA1 or BRCA2 mutation (if the woman herself has not been tested), a strong family history of breast and/or ovarian cancer, prior chest radiation therapy (e.g., for Hodgkin lymphoma), as well as women with Li-Fraumeni, Cowden, and Bannayan-RileyRuvalcaba syndromes and their first-degree relatives.188 Women with an estimated 15%-20% lifetime risk, including women with dense breast tissue, should talk with their doctors about the benefits and limitations of adding MRI screening to their annual mammogram. MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%. Studies indicate that MRI is underutilized among high-risk women and overutilized by women who are not at high risk for breast cancer.189 MRI should supplement not replace mammography and should be done at facilities that are accredited by the American College of Radiology. Although MRI is more expensive than mammography, most major insurance companies will cover some portion of the cost if a woman is demonstrated to be at sufficiently high risk. Breast ultrasound Breast ultrasound is sometimes used to evaluate abnormal findings from a mammogram or physical exam. It is completed with a wand-like handheld device that captures images of the breast with sound waves. For women with mammographically dense breast tissue, ultrasound combined with mammography may be more sensitive than mammography alone; however, it also increases the likelihood of false-positive results.190, 191 The use of ultrasound instead of mammograms for breast cancer screening is not recommended. Table 6. Mammography (%) by State, Women 45 and Older, 2016 Up to date* (≥ 45 years) Within the past 2 years (50-74 years) Alabama 72 78 Alaska 58 68 Arizona 66 76 Arkansas 65 73 California 71 82 Colorado 64 74 Connecticut 77 86 Delaware 76 82 District of Columbia 72 84 Florida 75 82 Georgia 72 79 Hawaii 74 84 Idaho 58 64 Illinois 69 78 Indiana 64 72 Iowa 71 78 Kansas 68 75 Kentucky 71 77 Louisiana 70 78 Maine 73 81 Maryland 74 81 Massachusetts 78 86 Michigan 71 79 Minnesota 73 82 Mississippi 65 72 Missouri 69 76 Montana 66 74 Nebraska 64 73 Nevada 62 73 New Hampshire 73 82 New Jersey 73 81 New Mexico 60 72 New York 70 80 North Carolina 72 79 North Dakota 69 75 Ohio 70 77 Oklahoma 66 74 Oregon 66 74 Pennsylvania 68 76 Rhode Island 79 85 South Carolina 68 76 South Dakota 72 79 Tennessee 68 77 Texas 64 73 Utah 65 77 Vermont 70 79 Virginia 73 80 Washington 66 76 West Virginia 71 78 Wisconsin 72 80 Wyoming 57 64 United States (median) 70 78 *According to American Cancer Society recommendations: mammogram within the past year (ages 45-54 years) or past two years (ages ≥55 years). Note: Mammography prevalence estimates do not distinguish between examinations for screening and diagnosis. Source: Behavioral Risk Factor Surveillance System, 2016. ©2019, American Cancer Society, Surveillance Research Breast Cancer Facts & Figures 2019-2020 23 Clinical breast examination (CBE) The American Cancer Society no longer recommends CBE for breast cancer screening in average-risk asymptomatic women based on lack of clear benefits for CBE alone or in conjunction with mammography.174 Furthermore, there is some evidence that adding CBE to mammography screening increases the rate of false positives. Breast self-awareness Although the American Cancer Society also no longer recommends that women perform monthly breast self-exams (BSE), all women should become familiar with both the appearance and feel of their breasts and report any changes promptly to their physician. If a lump or other symptoms develop, women should contact a doctor immediately, even after a recent normal mammogram. Breast Cancer Treatment Treatment decisions are made jointly by the patient and the physician after consideration of the stage and biological characteristics of the cancer, the patient’s age, menopausal status, and preferences, and the risks and benefits associated with each option. Ductal carcinoma in situ Since there is currently no certain way to determine the progressive potential of a DCIS lesion, surgery and sometimes radiation and/or hormonal therapy are the usual course of action following a diagnosis of DCIS. However, there is likely a group of patients that could safely forgo surgical treatment for DCIS.192 Several clinical trials