Get a mammogram every year or every two years? Start at age 40 or 50? What’s better–a mammogram, digital mammogram, breast ultrasound or breast MRI?
Many women are confused about mammography, and it’s no wonder. For years, doctors have been debating and changing breast cancer screening guidelines. It seems like our bras last longer than mammography recommendations do.
“I’m confused about how often to get a mammogram,” says Lynn Davis, 54, of Round Lake Beach. “You go by what your doctor tells you to do, and how do you know your doctor is following the latest recommendations?”
To answer some of the most common questions, WomanNews asked experts about screening mammograms, the low-dose X-rays of the breast performed when women have no symptoms of breast problems.
Are mammograms worthwhile?
The mammography debate intensified in 2001, when Danish researchers found no reliable evidence that mammography screening reduces the death rate from breast cancer. In 2002, however, an American Cancer Society panel of experts reviewed the research and concluded that mammography greatly reduces deaths due to breast cancer. Furthermore, the cancer society says that mammograms can find many cancers at their earliest stage, up to two years before the tumor is large enough to be felt.
“Mammography does save lives,” said Dr. David Winchester, an Evanston surgeon and a spokesman for the American College of Surgeons.
Yet everyone agrees that mammography is not perfect. An X-ray film may appear abnormal when no cancer is present, causing women needless worry and biopsy procedures. More important, mammography misses almost 2 of every 10 breast cancers, according to the National Cancer Institute.
“Women are concerned, and rightly so, that mammography may not find a cancer if there is one,” said St. Louis radiologist Dr. Barbara Monsees. “Although mammography is not going to find every breast cancer, it’s still the best test we have for early detection.”
– When should I start getting mammograms?
Most guidelines in the United States now recommend screening mammograms for every woman age 40 and over, according to the National Academies’ Institute of Medicine. If you are at increased risk of breast cancer (see sidebar on risks), the American Cancer Society’s 2003 guidelines suggest that you talk to your doctor about whether to start mammography screening earlier than age 40.
For women with a strong family history of the disease, screening typically starts a decade earlier than the age at which their relative received a breast cancer diagnosis, said Dr. Clement Rose, a Chicago internist and vice president of the American Cancer Society Illinois Division.
“If your mother had breast cancer in her 40s, … I’m going to recommend you get a mammogram in your 30s,” he said.
Rose also counsels black women to get their first mammogram between ages 35 and 40. Breast cancer appears to be more aggressive in black women, although, he said, they are at lower risk of breast cancer than white women.
“We’re finding metastatic breast cancer in black women in their early 40s, so screening should probably start five years earlier than in white women,” Rose said.
Rather than earlier, however, black (and Hispanic) women receive their first mammogram on average a year later than white women–at age 41, according to a study published Sept. 13 in the online edition of the journal Cancer.
– How often should I get a mammogram?
The American Cancer Society recommends that women who are 40 or older and at average risk of breast cancer have annual screening mammograms, in addition to a yearly clinical breast exam by a physician. Women at increased risk should talk to their physician about whether they need mammography more often than yearly, the society’s new guidelines state.
Not everyone agrees with annual mammography. Both the U.S. Preventive Services Task Force and the National Cancer Institute advise mammography screening every one to two years.
Monsees believes that waiting every other year to get a mammogram may be detrimental, especially for younger women, in whom breast cancer may grow quickly. Because breast cancers may grow more slowly after age 70, older women may change their mammography routine from annually to every two years, both she and Rose said.
Some women choose to have mammograms less often because they have no family history of breast cancer. Monsees said to not let that fact prevent regular mammograms. Most breast cancers occur in women without a family history of the disease, the American Cancer Society reports.
– When should I stop getting mammograms?
The value of mammography in older women is still under debate. In its new guidelines, the American Cancer Society says to continue mammography as long as a woman is in reasonably good health and would be a candidate for treatment if cancer were found. The National Cancer Institute reports that mammography may be helpful for women age 70 or older but firm evidence is lacking.
After age 80, women might not need a mammogram, Rose said. The decision depends on their individual risk factors for breast cancer.
– Should I get a breast MRI instead of a mammogram?
Magnetic resonance imaging, or MRI, shows promise for improved detection of breast cancer. The high cost of MRI precludes its use in all women, however. Women known to be at increased risk of breast cancer may benefit from MRI or breast ultrasound, according to the American Cancer Society. Breast ultrasound, like MRI, gives clearer pictures of dense breast tissue than does mammography. Ultrasound also can distinguish a cyst from a solid tumor.
If a woman gets a breast ultrasound or MRI, it should be in addition to mammography, not instead of it, Monsees emphasized.
“The gold standard for screening is still mammography,” the American College of Surgeons’ Winchester said.
– Is digital mammography better than standard mammograms?
Digital mammograms create images like a digital camera. A national clinical trial is studying whether the far costlier digital mammograms are better than film at finding early-stage cancers. Results should be out early next year.
– – –
BSE optional
The newest breast cancer screening guidelines from the American Cancer Society state that monthly breast self-examination, or BSE, is now optional for women. According to the cancer society, research shows that BSE plays a small role in detecting breast cancer compared with either mammography or a woman incidentally finding the lump.
The main benefit of BSE, said Dr. Clement Rose, a spokesman for the cancer society’s Illinois Division, is that it allows women to know how their breasts normally feel so they can detect any changes. He thinks women should still combine BSE with regular clinical breast exams and mammograms.
“BSE is [free], simple and private,” Rose said.
— K.L.
Possible signs of breast cancer
– A lump–most often painless (though most breast lumps are not cancerous)
– Less commonly, breast pain with no lump
– Changes to the breast that do not go away, such as swelling, skin irritation or a dimple in the skin
– Nipple changes, such as discharge, pain, redness, scaliness or turning inward
Source: American Cancer Society
– – –
Risks for breast cancer
Besides her gender, these are the known risk factors for breast cancer that a woman cannot control:
– Age over 50 and especially after 65.
– Inherited gene mutations for breast cancer, found on genetic testing.
– A first-degree relative (mother, sister, aunt or daughter) with breast cancer, and especially two or more first-degree relatives with breast cancer diagnosed before age 50.
– Personal history of breast cancer or, to a lesser degree, endometrial, ovarian or colon cancer.
– Prior biopsies resulting from benign breast conditions, especially atypical hyperplasia–abnormal but not yet cancerous cells.
– Start of menstruation before age 12 or menopause after age 55.
– Ashkenazi Jewish ancestry and a family history of breast or ovarian cancer.
Lifestyle risk factors that often can be controlled:
– Not having children, having the first child after age 30 or never breast-feeding.
– Use of birth control pills within the past nine years.
– Use of hormone replacement therapy for several years or longer.
– Postmenopausal obesity.
– Drinking two or more alcoholic drinks a day.
Source: American Cancer Society
