Should women begin mammography at 40 or 50 years old? Should women get a mammography annually or bi-annually? You may be confused by the conflicting recommendations of government and breast cancer organizations. My answer, as a fellowship trained breast-imaging specialist with decades of experience, is that most women should have annual mammograms beginning at age 40, earlier if you have a family history of cancer. But that’s not the whole story. Mammography is still the gold standard for breast cancer screening, but it’s just the beginning. You may need more.
Our bodies may be similar, but medicine in all fields is beginning to recognize that screening and treatment must be targeted to an individual’s unique profile. Personalized medicine is the trend of the future. This makes it difficult for governments who have to set policy based on numbers. When it comes to making decisions about your own health, you have to know what’s right for you.
Breast cancer is a concern for all women. Early detection leads to the best outcome: less invasive treatment, less possibility of complications and more time for breast cancer patients to be with the people they love. Although the benefit of early detection has been proven unequivocally, there are physicians writing that early detection is leading to overtreatment for cancers that wouldn’t have caused harm if left alone. This is a form of Russian roulette; we don’t know which chamber has the bullet. More specifically, the only way to know the aggressive character of a tumor is to remove it and analyze the tissue. Someday, early detection will be paired with early prediction. But we’re not there yet. Until that day, our mantra must be: find cancer as early as possible, and remove it or treat it hormonally with medication.
So, what’s the best path to early detection? If mammography is still the gold standard, why isn’t it enough? If you have certain risk factors, mammography alone may not be able to do the job.
Breast density is a risk factor that has only recently been acknowledged. Breasts are composed of fatty and glandular tissue. A breast is dense if it has lots of white glandular tissue. In mammography, tumors are white and tissue is white so the cancer can be hard, if not impossible, to differentiate from the tissue. Some studies show breast density is a risk factor in itself. An excellent resource is http://densebreast-info.org.
I initiated and testified for a law in New Jersey to require mammography providers to let patients know about breast density. New Jersey became the 14th state to pass a breast density notification law in 2014; there are now 30 states with some form of this legislation. Without legislation, radiologists were required to give referring physicians reports about their patients’ breast density but nobody had to tell patients and few did. Women whose cancers were found at an advanced stage after being missed on mammograms started Are You Dense (http://www.areyoudense.org) and DENSE NJ (https://www.facebook.com/DENSE.NJ).
The New Jersey law is not as specific as I would like (it tells patients they may have dense breasts and they should get results from their doctors), but it does start the conversation about breast density as an important factor in your health. The New Jersey law also requires health insurance providers to cover supplemental screening if your breast density is high enough.
We have a well-stocked toolbox of screening modalities to look for cancer. Digital Breast Tomosynthesis, sometimes called 3D mammography, is becoming standard. Tomosynthesis is an enhanced form of mammography. It captures pictures of the breast similar to flipping pages through a book, so more can be seen. At my practice, Women’s Digital Imaging of Ridgewood, we perform Tomosynthesis with C-View, specialized software that combines the 3D images back into a 2D image for a complete picture, which means that only one exam is necessary. Therefore, the radiation dose and time in compression are the same as with a standard digital mammogram.
Breast ultrasound is another screening tool that helps find tumors in dense breasts. With ultrasound, tumors are gray and stand out in dense white tissue. We often recommend alternating mammography with ultrasound so every six months you are being monitored for interval cancers (ones that develop between mammograms). Another way to spot abnormalities, particularly for women with extensive dense tissue, is with screening technology that shows how cells behave, as opposed to how they look. These tools include Magnetic Resonance Imaging (MRI) and molecular imaging, such as the system we use, Breast Specific Gamma Imaging (BSGI).
Family history is a crucial risk factor. All women should have an extensive review of their family history, maternal and paternal, to look for breast and ovarian cancer as well as colon, melanoma and pancreatic cancers. We review the family history of all our patients to determine who may be a candidate for genetic screening. We have the availability of an immediate teleconference with a genetic counselor when the patient comes for her mammogram, and can also perform the simple saliva test at that time. If you know you have a genetic abnormality that increases your risk for breast cancer, you can make better decisions about the types of screening you need and the frequency. You can also consider preventive treatment.
You can frequently find a study to validate any position you want. But it’s clear to me that accurate, reliable studies have proven that mammography has decreased mortality from breast cancer and that early detection increases both survival and quality of life. A recent study published in Cancer Magazine found that annual breast cancer screening with mammography starting at age 40 results in a nearly 40 percent reduction in breast cancer-specific deaths compared with screening at less frequent intervals. Adding ultrasound and other modalities increases the number of cancers found which again leads to earlier and better treatment.
Leave the statistics about over diagnosis to policy makers. When it comes to your own body, use my mantra: find it early; treat it early.
By Lisa Weinstock, MD
Dr. Lisa Weinstock is a radiologist in Ridgewood. She received her medical degree from State University of New York Downstate Medical Center College of Medicine and has been in practice for more than 20 years.