This patient should now be screened with mammography and accompanying breast MRI on an annual basis. Women who received chest wall radiation (such as mantle radiation therapy for Hodgkin lymphoma) between the ages of 10 and 30 years are at high risk for developing breast cancer and, according to the American Cancer Society 2007 guidelines, should be screened with breast MRIs as well as annual mammograms. Such women have a 30% to 50% lifetime risk of developing breast cancer within the radiation field. A recent study from England and Wales reviewed the incidence of breast cancer in 5002 women treated with supradiaphragmatic radiation therapy for Hodgkin lymphoma before age 36 years. This study showed an increased breast cancer risk starting 10 years after radiation exposure and peaking 25 to 34 years after exposure. At the 40-year follow-up, the risk of breast cancer was 48% for patients who received 40 Gy or more of mantle radiation therapy at a young age. Breast MRI is more sensitive, although less specific, than mammography for the detection of invasive breast cancers and has been studied prospectively in women with a high risk of breast cancer. However, mammography may still detect cancers not seen on MRI; therefore, a dual imaging strategy is recommended. In one study, the combination of mammogram and breast MRI had a sensitivity of 0.94 for detecting invasive breast cancer compared with a sensitivity of 0.39 with mammogram alone.

For the reasons noted above, yearly mammograms alone are less effective than a screening program including breast MRI.

Some groups, including the American Cancer Society, recommend annual mammography starting at age 40 years for women with an average breast cancer risk, whereas the American College of Physicians and the United States Preventive Services Task Force suggest initiating discussion with patients between the ages of 40 to 49 years who are at average risk for breast cancer regarding the risks and benefits of screening to determine the appropriate screening approach. Additionally, none of these groups recommends the use of MRI in screening for breast cancer in average risk women. This woman's breast cancer risk is far above average, and delaying mammography would be an inadequate screening approach for her.

There is no evidence that breast self-examination (BSE) decreases breast mortality. Some expert groups raise concerns about increased harm with BSE, such as unnecessary distress and procedures for benign lumps. Most guidelines from expert groups recommend against BSE, with a few recommending “breast self-awareness” or education about the benefits and limitations of BSE. BSE alone as a screening strategy in this high-risk patient is inadequate.