Mammograms Guidelines –The Picture of Health

As you move through the menopausal transition, taking care of your personal health will likely migrate to the top of your list and that includes annual mammograms.  However, even the experts disagree as to when and how often you should take pictures of your ‘breast friends.’

The American Cancer Society (ACS); the National Comprehensive Cancer Network (NCCN) and the US Preventive Services Taskforce (USPSTF) have issued varying guidelines on mammography screening, so I sought clarification from Dr. Anees Chagpar, Associate Professor of Surgery (Oncology) and Director of The Breast Center at Smilow Cancer Hospital at Yale-New Haven.

Her generous expertise will help us take care of our friends in need that have served us well through puberty, breastfeeding and let’s face it—first base.

First Date

This year alone, nearly a quarter of a million new cases of invasive breast cancer will be diagnosed. It is estimated that 40% of diagnosed breast cancers are detected by women who feel a lumpthrough self-exams.

Many of you received your first pink rose at the breast cancer screening facility around age 40.  This is because before the age of 40, women’s breasts are often too dense to see through. In addition, breast cancer is rare in women under 40 so exposure to radiation at a young age is not warranted. This turning-point magic age of 40 is something the ACS and NCCN still recommend, although the USPSTF does not:

The USPSTF recommends against routine screening mammography in women aged 40-49.  The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context including the patient’s values regarding specific benefits and harms. Grade: C recommendation (*There is moderate certainty that the net benefit for women under 50 is small.)

“Personally, I advocate annual screening starting at age 40, but tailor this recommendation to individual patients,” says Dr. Chagpar.  She further points out that women under 40 need not get a mammogram – unless they have a strong family history of breast cancer being diagnosed at an early age; in which case she recommends that women should have a baseline mammogram 10 years before the earliest diagnosis of breast cancer in their family.

Getting to Know You

How many of you conduct your own breast self-exam?  Dr. Chagpar says there is limited data from large randomized controlled trials on whether the self-exam results in improvements in survival.  However, Dr. Chagpar feels that if you’re comfortable with doing a self-exam, it is a good way to get to know your body so that you can apprise your doctor of any changes, lumps or abnormalities.

“Women should also be cognizant about their breast cancer risk, and clinical breast exams should be part of women’s annual physical.  If a women or her doctor feel a lump, note a suspicious skin change, or see bloody nipple discharge, further workup is warranted, regardless of the patient’s age. The reason why some doctors don’t recommended self-exam is that, for some women, it increases anxiety and they might be unsure if they are “doing it right” or if what they feel is something to be concerned about.”

Middle of the Roaders

For those beyond the age of 49, the USPSTF recommends only biennial, not annual, screening mammography.

Dr. Chagpar believes there are several good reasons to continue annual screenings.

“There have been a number of randomized controlled trials that have shown the benefit of mammography – the majority of these have been with biennial screening in women 50-74 (although some also excluded women over the age of 70).  Hence, the USPSTF’s recommendations.  However, there is also a plethora of data that women under the age of 50 (particularly in their 40s) also get breast cancer, and may benefit from early detection with mammography.  Furthermore, there are interval cancers that may arise between biennial screenings, and hence, the American Cancer Society recommends annual mammography starting at age 40.”

So, why don’t all three organizations agree on guidelines?

“The data are accurate – it’s the interpretation of the data, and the formulation of the guideline that varies.  There isn’t just variation between the USPSTF and the ACS – there is global variation as well.  In Canada and the UK, for example, recommendations are for mammography every 2 years starting at age 50,” finishes Dr. Chagpar.

Additional Tests

The American Cancer Society recommends regular breast MRIs, in addition to mammograms for women over 40 at high risk for breast cancer and as a possible follow-up for abnormalities found by mammograms. The New England Journal of Medicine published studies that concluded MRIs are more effective than simple mammography for women at high risk.

Dr. Chagpar concurs with these findings. “Women who have a BRCA 1 or 2 gene mutation, women who have not undergone genetic testing but who have a first degree family history of such a mutation, or women who have a lifetime risk of 20-25% based on BRCAPRO or similar models may opt to have annual MRI as there are data that in this high risk population, MRI may be of benefit. MRI is not routinely recommended after a mammogram but may be useful as an adjunct, and may also be useful in particular situations: for example, to look for a primary breast cancer in patients presenting with a metastatic lymph node with a normal mammogram, or patients who have implants in whom there is suspicion of a leak.”

They Can See Right Through You

I asked Dr. Chagpar to tell us about the new breast tomosynthesis mammography that finds 41% more invasive cancers according to two large, retrospective studies published in The Journal of Roentgenolgy (AJR) and The Journal of the American Medical Association. (JAMA).

“This is simply a means for mammography to take serial thin slices through the breast tissue rather than a cumulative picture…kind of like slicing a loaf of bread into thin slices and looking at each slice rather than trying to see through the whole loaf.  This technique has been shown to reduce the number of call-backs for abnormal screening mammograms and may be helpful in women with dense breast tissue,” explains Dr. Chagpar.

In fact, the doctor says that many centers are actually replacing traditional mammography with tomosynthesis for this very reason, and while insurance companies may not have a separate code for the new technology, it is usually reimbursed at the rate of mammography.  She suggests asking your own facility if they offer the procedure and whether your insurance will cover it.

Continuing the Relationship

There is much conversation in the media these days about the costs of cancer prevention and whether or not we are “over diagnosing.” I am a firm believer that knowledge is power. When I asked Dr. Chagpar what the right age is to discontinue annual mammography, she responded, “What is your general health like?  If you are 65, but have heart failure and cirrhosis such that you would choose not to treat a breast cancer if found on a screening mammogram, there is no reason to get the test. However, if you are 79 and run a mile every day, play tennis on the weekends and anticipate significant longevity, you may want to detect and treat any cancer early and should therefore continue to get mammograms until such time you wouldn’t.”

You Have the Power

The American Cancer Society recommends 150 minutes of physical activity per week to keep those free radicals in line.

Researchers estimate that cancer may be reduced by 9% simply by changing our diets and most studies point to fat as a solid D-lister when it comes to breast cancer.

Breast Intentions

So, a lot of it comes down to the piece of advice given to Julia Roberts’ character in Pretty Woman – ‘you take care of you.’  Know your body and be aware of your family history to make an informed decision.  Taking care of the younger you will have the older you thanking yourself for being so proactive.

It’s the breast thing you can do!

Suffering in Silence is Out!  Reaching Out is In!