A 26-Year-Old Woman, Gravida 0 Para 0, Comes to the Community

A 26-year-old woman, gravida 0 para 0, comes to the community health center for an annual physical examination.  She is concerned, as her grandmother recently died of metastatic breast cancer at age 68.  The patient states, "Ever since my grandmother died, I have been worried about breast cancer.  I think I need a mammogram."  She has no chronic medical conditions and has had no surgeries.  Her periods are regular, every 28 days with 4 days of moderate bleeding; the last menstrual period was 2 weeks ago.  Menarche was at age 13.  The patient is sexually active without contraception and planning a pregnancy within the year.  Other than breast cancer in her paternal grandmother, family history is noncontributory.  The patient takes a daily prenatal vitamin and does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98 F) , blood pressure is 110/70 mm Hg, and pulse is 70/min.  BMI is 20 kg/m².  Breast examination shows no masses bilaterally, and the right breast is slightly larger than the left.  No nipple discharge, skin dimpling, rash, or lymphadenopathy is present.  She notes that the breast asymmetry has been present since puberty.  Which of the following is the most appropriate response to this patient?

A) Given your family history, MRI of the breast would be the best screening strategy.
B) If a pregnancy test is negative, we can perform a screening mammogram.
C) Monthly breast self-examination is the best screening strategy, given your history, and should be performed after menses.
D) We can assess your risk for breast cancer with a genetic test for the BRCA1/BRCA2 mutation.
E) You are at a low risk for breast cancer, so screening tests are not indicated at this time.