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Top 5 Breast Screening Questions: Experts share their advice

Breast Cancer Awareness Month is right around the corner. This year, many women are faced with new questions and concerns about their breast health as a result of the COVID-19 pandemic. The good news is that many hospitals and screening centers have now returned regular breast cancer screening, with enhanced safety measures put in place to reduce the possible spread of COVID-19. 

GE Healthcare spoke to several women’s health radiologists and Ob-Gyns across the country about the five most commons questions they hear about screening and what advice they would share with their own loved ones on the topic of breast screening. The panel included:

  • Dr. Joseph Russo, Radiology, St. Luke’s University Health Network
  • Dr. Marc Roy, Radiology, Northwest Community Hospital
  • Dr. Bruce Schroeder, Radiology, Carolina Breast Imaging Specialists
  • Dr. Christina Clemow, Radiology, MetroHealth System
  • Dr. Serena Tidwell, Obstetrics & Gynecology, Midtown OBGYN
  • Dr. David Patton, Obstetrics & Gynecology, Dr. David Patton, MD, Inc

1. When to get a mammogram

Dr. Bruce Schroeder, Radiology, Carolina Breast Imaging Specialists. There is broad agreement, that to find the maximum number of breast cancers and save the greatest number of lives, and certainly, to save the most years of life, screening mammography should begin at age 40 and continue for as long as the woman is in good health. Of course, if there is a strong family history, screening may start earlier and other tests may be needed in addition to mammography.

Dr. Christina Clemow, Radiology, MetroHealth System: You should start your annual screening mammograms at the age of 40, as do most major medical societies. As a breast radiologist, I am looking for subtle differences in your breasts from year to year and having a yearly mammogram is very important. You may continue annual mammograms while you are in good health with a reasonable life expectancy and willing and able to undergo treatment, if necessary.

Dr. Serena Tidwell, Obstetrics & Gynecology, Midtown OBGYN: The recommendations have been confusing; however, when you look at many of these recommendations, they talk about cost savings in spacing out mammograms. I strongly believe in annual mammograms starting at age 40. My mother is a low risk patient, and that is my approach for low or average risk patients. However, because my family has a genetic risk of breast cancer on my paternal side, I would explain to my daughter that her approach needs to be individualized for her specific risk.

2. What are the most common risk factors for breast cancer?

Dr. Clemow: Most women that are diagnosed with breast cancer do not have a family history. In fact, 75% of women with breast cancer are not at high risk for the disease. However, there are some factors that may increase your risk of developing breast cancer, such as having first-degree relatives with breast cancer or being a BRCA1 or BRCA2 gene carrier. Other factors such as race and ethnicity, having dense breast tissue, some benign breast diseases, and certain lifestyle-related risk factors can increase your risk of developing breast cancer.

Dr. Tidwell: I recommend having your mammogram at a breast center that calculates a personalized breast cancer risk score for each patient. Given the new federal density law, we know that all patients will be informed of their breast density. So, in addition to annual mammograms, we all need to know our breast density and our risk score. These two factors determine the need for any supplemental screening in addition to an annual mammogram.

Dr. David Patton, Obstetrics & Gynecology, Dr. David Patton, MD, Inc.: Some risks are uncontrollable and some we have control over.  First, just getting older increases a woman’s risk to get breast cancer. One in 8 women will get breast cancer in their lifetime. Some women carry genetic mutations like BRCA1 and BRCA2 that greatly increases their risk, and these are picked up in women who have family histories of breast cancer or other certain types of cancer. Starting a period before age 12 or going into menopause after age 55 are also risk factors. Dense breast tissue is an additional uncontrollable risk factor and statistically found in 4 out of 10 women.

Factors that women have some degree of control over include lack of physical activity, being overweight, taking certain hormones, drinking alcohol, and having a first baby after age 30. For those with dense breasts, I would recommend an ABUS (automated breast ultrasound) following a yearly mammogram. 

3. What's the difference between 2D mammograms and 3D mammograms?

Dr. Joseph Russo, Radiology, St. Luke’s University Health Network: 3D mammography affords breast imagers the advantage of cross-sectional imaging that is often the standard of care in radiology (as in CT or MRI scans). 

Dr. Schroeder: It’s like the difference between window shopping by strolling down the street where you can see some of what’s inside the store through the window versus going in and walking down each aisle where you can see the individual items.  3D mammography gives us much more detailed information by eliminating the overlap of tissues. 

Dr. Tidwell: 3D technology makes it easier for the Radiologist to interpret your mammogram. 3D adds a level of detail to the imaging that can be very useful in cancer detection. The additional radiation exposure is negligible.

4. How does dense breast tissue affect breast cancer risk?

Dr. Schroeder: The more non-fatty normal breast tissue that you have, the harder it is to find the abnormal tissue. Since dense tissue represents active breast tissue and active tissues are more likely to become abnormal than inactive tissues, density is also a marker of breast cancer risk. So, if you have dense tissue, you have a higher risk of developing breast cancer while also making it harder to find on mammograms. For these reasons, if you have dense tissue you may want to consider adding an additional test (such as automated breast screening ultrasound) that can see through the dense tissue.

Dr. Marc Roy, Radiology, Northwest Community Hospital. Although a screening mammogram is still the primary exam that physicians recommend for breast cancer screening, studies have shown that women with dense breasts benefit from additional ultrasound screening (ABUS).

Breast tissue looks white on a mammogram, but unfortunately breast cancer also typically looks white. As a result, there is often not sufficient contrast between the normal dense breast tissue and cancer.  Small cancers may therefore be obscured. Dense breast tissue also looks white on an ultrasound, but with ultrasound, most breast cancers look dark. This often allows the radiologist to detect small breast cancers with ABUS that could not be visualized on the mammogram.

Dr. Clemow: 40% of all women are noted to have dense breast tissue. When we look at your mammogram, the dense breast tissue is white, but so is cancer. This is why the dense breast tissue can make it difficult for us to identify cancer that may be growing in the dense breast tissue. Secondary screening exams, such as automated breast ultrasound (ABUS), is an option to screen dense breasts in conjunction with mammography. The ultrasound allows us to see through the dense tissue and identify abnormalities that we cannot see on your mammogram, such as, hard-to-see cancers and other benign etiologies. 

5. What does it mean if I'm called back for a biopsy?

Dr. Russo: I would underscore the fact that most breast biopsies are negative. Today, advanced technologies help us locate and biopsy very small suspicious areas, as opposed to the past when most biopsies were for palpable abnormalities.

Dr. Schroeder: Women who come for biopsy are anxious about two things: the procedure and the results. The procedure is very common and most women are surprised at how fast it is, and usually comment that they didn’t feel any pain at all. As far as the results, most biopsies do not show cancer. On average, cancer is found in much less than 50% of the biopsies performed. 

Dr. Tidwell: My mom really doesn’t like going to the doctor! So, the first thing I would tell her is the biopsy is truly NOT that big a deal. It’s likely going to be benign, but it’s important to get the biopsy. And, if it’s not benign, it’s likely very early. That’s why we do mammograms – to detect the early cancers!