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Appropriateness Criteria

Variant 1: Breast cancer screening. Transfeminine (male-to-female) patient, 40 years of age or older with past or current hormone use equal to or greater than 5 years. Average-risk patient.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening May be appropriate Strong ☢☢ 0.1-1mSv 6 6 0 0 0 2 7 5 4 0 1
References Study Quality
2 (31088823) 4
21 (25994431) 4
1 (25428790) 4
3 (24010586) 4
18 (21266549) 4
10 (29392096) 4
19 (9718051) 2
20 (12117397) 2
Mammography screening May be appropriate Strong ☢☢ 0.1-1mSv 6 6 0 0 0 1 7 4 5 1 1
References Study Quality
2 (31088823) 4
21 (25994431) 4
1 (25428790) 4
3 (24010586) 4
18 (21266549) 4
10 (29392096) 4
19 (9718051) 2
20 (12117397) 2
US breast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 1 3 1 0 1 0 0 1
References Study Quality
11 (19359116) 3
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 1 2 1 4 0 0 0 1
References Study Quality
4 (25415740) 4
10 (29392096) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 15 0 1 1 1 0 0 0 1
References Study Quality
17 (29724416) 4
Variant 2: Breast cancer screening. Transfeminine (male-to-female) patient, 25 to 30 years of age or older with past or current hormone use equal to or greater than 5 years. Higher-than-average risk (patient with personal history of breast cancer or chest irradiation at 10 to 30 years of age, patient with genetic predisposition to breast cancer, patient with family history of breast or ovarian cancer, and untested patient with first-degree relative with genetic predisposition to breast cancer).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening Usually appropriate Strong ☢☢ 0.1-1mSv 7 7 0 0 0 0 1 3 12 0 3
References Study Quality
25 (29101979) 4
2 (31088823) 4
1 (25428790) 4
24 (25042481) 4
3 (24010586) 4
18 (21266549) 4
19 (9718051) 2
20 (12117397) 2
22 (31526252) 3
Mammography screening Usually appropriate Strong ☢☢ 0.1-1mSv 7 7 0 0 0 0 1 1 13 1 3
References Study Quality
25 (29101979) 4
2 (31088823) 4
1 (25428790) 4
24 (25042481) 4
3 (24010586) 4
18 (21266549) 4
10 (29392096) 4
19 (9718051) 2
20 (12117397) 2
22 (31526252) 3
US breast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 3 0 0 0 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 3 8 1 1 1 1 0 0
References Study Quality
4 (25415740) 4
10 (29392096) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 17 2 0 0 0 0 0 0 0
References Study Quality
17 (29724416) 4
Variant 3: Breast cancer screening. Transfeminine (male-to-female) patient with no hormone use (or hormone use less than 5 years) at any age. Average-risk patient.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 3 0 0 0 1 0 0 1
Digital breast tomosynthesis screening Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 14 2 1 0 0 0 0 0 2
References Study Quality
1 (25428790) 4
26 (22393212) 4
Mammography screening Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 14 2 1 0 0 0 0 0 2
References Study Quality
1 (25428790) 4
26 (22393212) 4
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 2 1 0 0 0 0 0 1
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 14 2 1 1 0 0 0 0 1
References Study Quality
17 (29724416) 4
Variant 4: Breast cancer screening. Transfeminine (male-to-female) patient, 25 to 30 years of age or older with no hormone use (or hormone use less than 5 years). Higher-than-average risk (patient with personal history of breast cancer or chest irradiation at 10 to 30 years of age, patient with genetic predisposition to breast cancer, patient with family history of breast or ovarian cancer, and untested patient with first-degree relative with genetic predisposition to breast cancer).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening May be appropriate Limited ☢☢ 0.1-1mSv 5 5 0 1 0 1 12 2 3 0 0
References Study Quality
21 (25994431) 4
22 (31526252) 3
23 (31280425) 3
Mammography screening May be appropriate Limited ☢☢ 0.1-1mSv 5 5 0 1 0 1 11 3 3 0 0
References Study Quality
21 (25994431) 4
22 (31526252) 3
23 (31280425) 3
US breast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 1 0 0 1 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 8 1 1 3 0 1 0 0
References Study Quality
4 (25415740) 4
17 (29724416) 4
10 (29392096) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 18 0 1 0 0 0 0 0 0
References Study Quality
17 (29724416) 4
Variant 5: Breast cancer screening. Transmasculine (female-to-male) patient with bilateral mastectomies (“top surgery”) at any age and any risk.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 1 1 0 0 1
References Study Quality
28 (-3173791) 4
Digital breast tomosynthesis screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 15 2 1 0 0 0 0 0 1
Mammography screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 15 2 1 0 0 0 0 0 1
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 1 1 0 0 0 0 1
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 1 0 0 0 0 0 1
Variant 6: Breast cancer screening. Transmasculine (female-to-male) patient with reduction mammoplasty or no chest surgery, 40 years of age or older. Average-risk patient (less than 15% lifetime risk of breast cancer).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 1 0 0 0 1 2 3 12
References Study Quality
25 (29101979) 4
Mammography screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 1 0 0 0 0 0 1 5 12
References Study Quality
25 (29101979) 4
US breast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 8 2 0 3 6 0 0 0 0
References Study Quality
31 (20129267) 4
30 (25763719) 4
32 (25329763) 3
33 (23980217) 3
34 (23116728) 2
29 (23750571) 4
25 (29101979) 4
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 3 1 1 0 0 0 1
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 2 1 1 0 0 0 0 1
Variant 7: Breast cancer screening. Transmasculine (female-to-male) patient with reduction mammoplasty or no chest surgery, 30 years of age or older. Intermediate risk (patient with personal history of breast cancer, lobular neoplasia, atypical ductal hyperplasia, or 15% to 20% lifetime risk of breast cancer).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 1 0 0 0 1 2 5 10
References Study Quality
35 (28648873) 4
25 (29101979) 4
Mammography screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 1 0 0 0 0 0 1 6 11
References Study Quality
35 (28648873) 4
25 (29101979) 4
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 1 2 13 2 1 0 0
References Study Quality
40 (18477782) 1
41 (22474203) 1
25 (29101979) 4
MRI breast without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 0 1 12 3 1 1 0
References Study Quality
38 (20651211) 3
37 (21900617) 4
36 (21900618) 3
39 (26744477) 3
25 (29101979) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 1 0 1 0 0 0 1
Variant 8: Breast cancer screening. Transmasculine (female-to-male) patient with reduction mammoplasty or no chest surgery, 25 to 30 years of age or older. High risk (patient with genetic predisposition to breast cancer or untested patient with a first-degree relative with genetic predisposition to breast cancer, patient with a history of chest irradiation between 10 to 30 years of age, patient with 20% or greater lifetime risk of breast cancer).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 1 0 1 0 0 1 2 4 10
References Study Quality
35 (28648873) 4
42 (17392385) 4
25 (29101979) 4
Mammography screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 1 0 1 0 0 0 2 4 11
References Study Quality
35 (28648873) 4
42 (17392385) 4
25 (29101979) 4
MRI breast without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 0 1 2 7 8
References Study Quality
49 (17244718) 2
43 (17317184) 3
44 (16615112) 4
46 (16293877) 2
47 (15910949) 2
48 (24789418) 3
45 (20177029) 1
50 (19884532) 1
25 (29101979) 4
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 1 0 0 2 11 2 1 1 1
References Study Quality
40 (18477782) 1
41 (22474203) 1
25 (29101979) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 1 0 1 0 0 0 1
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.