Breast Cancer Screening
I recently attended the University of Illinois and Susan G. Komen co-sponsored, Eighth Annual Breast Cancer Symposium, 2015 in Peoria, IL. For the past eight years, these organizations have jointly sponsored well respected speakers from around the country to bring continued education to professionals in the area relative to breast cancer prevention, early detection, and the most up-to-date treatments for breast cancer. I want to share excerpts on the topic of “Controversies in Screening Mammography” addressed by Dr. Tara Henrichsen, MD, and Program Director of the Radiology program at Mayo Clinic.
October was Breast Cancer Awareness month. We have all been impacted by breast cancer—family members, loved ones, friends, even ourselves. One in every eight women will develop invasive breast cancer in their lifetime and there will be 231, 840 new cases of invasive breast cancer in 2015. The wonderful news is—the five year survival rate in the 1960s was 63% but today it is 89%! We have come a long way, indeed.
A mammogram is an x-ray of the breast. Screening mammograms are obtained to detect breast disease in women without any symptoms (or those that do not appear to have breast problems). Diagnostic mammograms, on the other hand, are used to diagnose breast disease in women that do have breast cancer symptoms, have a lump identified by themselves or their provider, or have an abnormal result on a screening mammogram. Most often, a digital mammogram (an image of the breast recorded on the computer instead of x-ray film) is obtained. The newer type of mammogram is called a breast tomosynthesis or 3D mammography which is a done by a machine that takes many low-dose x-ray images as it moves over the breast. Those images are recorded on a computer into a 3-dimensional picture allowing doctors to see problem areas more clearly.
A mammogram is performed to find cancers that can’t be felt by the woman or her provider. Often, if the mammogram shows an area of concern, the radiologist will suggest an ultrasound to further evaluate the area of concern. To confirm whether an abnormality seen on a mammogram is cancer, a small amount of tissue must be removed which is called a biopsy. A biopsy looks at the tissue under a microscope to determine if there is cancer.
A breast ultrasound can also be performed if a woman has dense breasts. Dense breasts are more common in younger women. At this time, the American Cancer Society guidelines do not contain recommendations for additional testing to screen women with dense breasts. In some states, legislation has been passed to allow ultrasound to be performed and covered by third party payers, but Illinois does not currently have this law.
Over the past few years, you may have asked yourself or your provider: “When should I get a mammogram? What age should I begin and how often should I get a mammogram?” This has been a controversial topic since the United States Preventive Services Task Force (USPSTF) drafted their breast cancer screening guidelines recently updated April, 2015. Basically, the USPSTF suggests that younger women do not need to be screened until age 50 if they have no abnormalities in their breasts nor any strong family history of breast cancer, and then only every two years. They have suggested that the most likelihood of developing breast cancer is between the ages of 50 and 74, therefore stopping screening at age 74 if there have been no abnormalities or strong family history of breast cancer. This has been very controversial in the medical community and Dr. Henrichsen from Mayo Clinic addressed the topic at the recent symposium, endorsing the following guidelines.
Breast Screening Guidelines*
- Women age 40 and older: Yearly mammograms and continue for as long as they are in good health. Clinical breast exam yearly by a health professional.
- Women ages 20s and 30s: Clinical breast exam as part of a periodic regular health exam by a health care professional, at least every 3 years. (We, at the Couri Center, prefer yearly exams).
- Breast Self Exam (BSE): An option for women starting in their 20s. Women should be told about the benefits and limitations of BSE (worrying over “doing it right”). BSE should be performed after the monthly period or on a regular basis. Some women prefer to do a formal self breast exam, others prefer to get to know how their breasts normally look and feel with the goal of both being to report any breast changes to your health care provider for further evaluation if you notice something “different“.
*American College of OB/GYN, American College of Radiology, and Mayo Clinic recommendations.
Dr. Henrichsen discussed the progress and modernization of the mammogram equipment over the years. The first x-rays were in the 1920s. In 1949, the compression mammogram technique was introduced and by 1956 most institutions had dedicated breast x-ray equipment. In the 1960s, xeromammogram (film screen like chest x-rays) was available and by the 90s, we had digital imaging available. Guidelines also have changed.
Dr. Henrichsen and Mayo Clinic radiology department endorsed the 2014 American Cancer Society breast screening guidelines and believes that early detection and screening will impact morbidity (quality of life or being unhealthful). The US Preventive Task Force only used data on mortality or death rates.
With more sophisticated equipment, such as digital mammography or 3D, studies show improved detection and less frequent “call backs” or biopsies.
The controversy has been unclear to patients and health care providers. Recommendations are confusing. Dr. Henrichsen commented on the new research that began in the United Kingdom in July of 2014 concerning the diagnosis of “Ductal Carcinoma in Situ” which some feel is controversial to treat. This study is looking at surgical intervention versus continued surveillance (watchful waiting). She indicated the number of women identified through screening mammograms that have benefited with early diagnosis and treatment compared to women who chose the “wait and see” approach which quickly developed into an invasive cancer of the breast.
Some women worry about the radiation risk with mammograms. The FDA website has a page on “Mammogram Myths” from 2003 which is also a good website to read, if you have concerns. Radiation risk is minimal and might be compared to the risk of radiation from just living in a brick building.
The Symposium also addressed women at higher risk for breast cancer based on family history and other risk factors. Several risk assessment tools are available, such as the Gail Model, most commonly utilized. These tools are available on-line to assist estimating a woman’s breast cancer risk. MRI and genetic testing are also further evaluations available if a person is at higher risk, but may not be covered by third-party payers.
Basically, the Mayo Clinic and Tara Henrichsen, MD, recommended women and health care providers follow the American College of OB/GYN (ACOG) and the American College of Radiologists’ recommendation to begin breast screening at age 40 and yearly after that, with no age limit as long as a woman remains in good health.
Here’s to your health and happy fall!
Terry Polanin, MSN, APN
Family Nurse Practitioner