Fig. 4.

Flow chart illustrating a screening decision support tool according to risk stratification. ^a High risk is defined as: women with a known or suspected pathogenic mutation in BRCA, TP53, CHEK2, PTEN, ATM, CDH1, STK11, and PALB2; women having a lifetime risk greater than 20% according to acceptable models that determine risk of pathogenic mutations, with Tyrer-Cuzick model the most accurate at the population level (and which includes breast density as a risk factor); women treated with chest or mantle radiation therapy by age 30 and at least 8 years prior. ^b A personal history of lobular carcinoma in situ confers almost as high a risk as personal history of breast cancer and such women should consider supplemental screening with MRI, especially if the breasts are dense. Atypical lobular hyperplasia (ALH) and atypical ductal hyperplasia (ADH) confer 20–25% lifetime risk as well but there are no studies showing improved cancer detection in women with ALH or ADH who undergo MRI screening in addition to mammography.