this approach ignores an important group of women.
Approximately 20 percent—one out of five—cancers we see in our practice are in women under fifty. Patients with cancer who started mammographic screening at age forty tend to be diagnosed with small, treatable breast cancers, while most of the advanced cancers are found in patients who have never had a mammogram.
Self-proclaimed “experts” who advise that screening start at age fifty have two reasons: One is that most women in their forties have such dense breasts on mammographic imaging (see chapter fourteen) that it’s hard to find small cancers . . . and, besides, “we all know” that fewer women in their forties develop breast cancer than women over fifty. The other is the much-touted concern about the issue of false positive biopsies. When the radiologist sees a worrisome spot on the mammogram, a needle biopsy is recommended. It is well-known that many of these biopsies will prove to be benign. The chance of a false positive is higher for younger women, in large part because many of these women are receiving their first mammogram and there are no previous images to check. When previous films are available for comparison, the number of false positive biopsies drop.
As the critics of early screening point out, a great deal of anxiety occurs when a woman is told she needs a breast biopsy. They conclude that the anxiety associated with a false positive biopsy is just one more reason why starting screening at age forty is not justified.
The critics, however, are not fair and balanced. They manage to overlook the downside—the anxiety associated with a delayed diagnosis. In my experience, most women are willing to take the chance of a false positive when it’s associated with a potential for detecting a breast cancer at an earlier stage—that interval when treatment is less aggressive and the probability of survival is improved. As one of my patients noted, “Both ways it’s good news: Either my doctor caught a malignancy early, while it’s easily treatable, or I learn I don’t have cancer.”
My advice to patients: Start mammographic screening at age forty and do it yearly. This advice applies to women at normal risk for breast cancer. Those with strong family histories or others who have been exposed to radiation at a young age are followed more aggressively, which may include yearly clinical exams starting at age twenty-one, yearly MRIs starting at age twenty-five, and yearly mammograms starting at age thirty.
BI-RADS CLASSIFICATION
The American College of Radiology established a standardized reporting system called BI-RADS (or Breast Imaging Reporting and Data System) that is used by all mammography centers in the USA—a major advance, as before we had such a system screening reports were often difficult to interpret. All mammogram reports are given a final BI-RADS score ranging from zero to six.
• A category 0 report means additional imaging is required.
• Categories 1 and 2 indicate a completely normal exam. A category 2 score means something is seen on the mammogram, like a cyst, but because it is inconsequential, the exam is still considered to be normal. For both categories, a one-year follow-up is recommended.
• Category 3 indicates the presence of something that is probably benign. A six-month follow-up is indicated.
• Categories 4 and 5 indicate a cancer is suspected (more so in 5 than in 4) and a biopsy is mandatory.
• Category 6 means the diagnosis of breast cancer has been made and further treatment is required.
How Often to Do Screening
There is also ongoing controversy about how often to do mammographic screening. Some guidelines suggest every other year is sufficient. I am not convinced and will not be until there is more data to prove that this is just as safe as yearly.
When to Stop Screening
Limited data indicates that screening beyond age seventy-four saves lives. The explanation for ever selecting this particular age as an endpoint is that previous studies arbitrarily stopped with women older than seventy-four. Despite the lack of proof, I recommend that yearly screening continue as long as a woman remains in good health.
Tips for Women Undergoing Screening
The most common complaint about screening mammography is the pain that occurs when the breast is compressed. Although many women breeze through the process, there are others who dread the anticipated discomfort. A few steps can be taken to reduce apprehension.
• Menstruating women should schedule their mammogram five to ten days after the onset of their period, when the breasts are least tender.
• Menopausal women who are on hormone replacement should consider stopping their hormones one week prior to the exam.
• All women who are concerned about discomfort should consider taking ibuprofen or their favorite anti-inflammatory an hour before the examination.
• If you had a bad experience with your previous mammogram, tell the person setting up the equipment. In some cases, an experienced technician can make adjustments that will improve the experience.
With this exam, two other issues become important. The first is underarm deodorant, which should be avoided the day of the procedure (and all traces of prior deodorant should be washed off). Particles in the product, such as aluminum, can cause confusion and may lead to needless additional views. The second issue is the need for convenient clothing; women should wear a two-piece outfit with an easily removable top.
New Advances in Screening
Critics eagerly point out that screening mammograms fail to visualize many breast cancers, and, unfortunately, they are correct. One of the most frustrating aspects of my practice occurs when one of my patients, who for years has followed all of the early detection guidelines, is diagnosed with a late-stage breast cancer (see chapter ten). Fortunately, this situation is unusual.
The good news is that recent technology is coming to the rescue. One of the major advances in detecting cancers missed on mammographic screening is adding additional screening for the approximately 50 percent of patients who, on mammograms, are found to have dense breasts (see chapter fourteen).
Studies have demonstrated that the number of small cancers detected in women with dense breasts almost doubles when ultrasound is added.
A second fallback is the breast MRI, which is even more effective than ultrasound in detecting small cancers missed on mammograms. Because of the cost and inconvenience, we limit screening MRIs to women who are at very high risk for developing cancer, such as Angelina Jolie.
A third advance is tomosynthesis, or 3-D mammography. The 3-D mammogram is just what it states. Rather than the standard 2-D image of the breast, multiple images are taken. The images are fed into a computer and a three-dimensional image is provided. One recent study concluded that 3-D detected 27 percent more cancers than did screening with 2-D mammograms. In addition, there was a 15 percent reduction in need to call women back for additional views.
My Advice on Mammograms
Although some experts might conclude that my approach to screening is overly cautious, I am convinced it will save lives and lead to less aggressive treatment.
