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Counseling Patients Based on Risk

Many women will receive notification of dense breast tissue on their screening mammogram. They may then seek consultation from their primary provider. The first step in counseling the patient is to clarify her individual risk of breast cancer. The flow charts define risk based on individual patient factors. The peach colored bars describe recommended approaches to subsequent screening.

High Risk

According to current guidelines from the NCCN, USPSTF, ACS, ACOG, and ACR, patients with the highest risk of breast cancer should undergo supplemental screening, whether or not they have dense breasts. As seen in the flow chart below, women with any of the listed factors denoting high risk should be screened with annual mammography and annual breast MRI, if feasible. Genetic counseling and/or medications to reduce the risk of breast cancer may also be recommended.

breast cancer high risk flow chart

Intermediate Risk

According to current guidelines from the NCCN, USPSTF, ACS, ACOG, and ACR, there is insufficient evidence to endorse supplemental breast cancer screening, specifically based on breast density, in intermediate risk patients. Nevertheless, Primary Care Providers will be asked to consider supplemental screening in these individuals, particularly those with extremely dense breasts. The decision-making should be informed by a number of factors including a review of the patient’s overall risk for breast cancer, the patient’s willingness to accept routine surveillance, the patient’s tolerance for a false-positive result from a supplemental test that may trigger subsequent intervention, and any financial implications associated with the cost of supplemental imaging.


Average Risk

The NCCN, USPSTF, ACS, ACOG, and ACR do not recommend routine supplemental screening for women with dense breasts without other risk factors since such screening is not validated to result in a decrease in mortality. Routine mammographic screening is recommended for these women.


  • NCCN: National Comprehensive Cancer Network
  • ACR: American College of Radiology
  • USPSTF: United States Preventive Services Task Force
  • ACOG: American College of Obstetricians and Gynecologists
  • ACS: American Cancer Society
  • BMI: Body Mass Index
  • CBE: Clinical Breast Exam
  • LCIS: Lobular Carcinoma in Situ