As a radiologist and a breast imaging expert, I am thrilled about the amount of solid study and research into breast health that is occurring these days. But with so many studies and so much data, the “latest news” can sound as if it contradicts the previous news, and women are understandably confused. I worry that women may not seek the care they need when they need it. Good breast care is a 3-part process: doing your own breast exam once a month, going to your doctor once a year for a good clinical examination, and then getting a regular screening mammogram. Below I’ve provided more information about what you should know about breast health and care and what you should do if an issue occurs.
I am also pleased to share that at Atrius Health, we offer 3D mammography at 5 convenient locations in and around Boston: Chelmsford, Somerville, Boston (Kenmore Square), Dedham and Weymouth. To make an appointment, patients can call a location directly or, for those who have a MyHealth Online account, can directly schedule at a location and time most convenient for them.
Starting Age for Screening Mammograms
To summarize the current guidelines by medical organization, the American College of Radiology, the Society of Breast Imaging (SBI), and the American Congress of Obstetricians and Gynecologists (ACOG) recommend starting your yearly mammogram (if you are at average risk) at age 40. Most breast imagers agree with this recommendation. The American Cancer Society recommends starting annual mammograms no later than age 45, but they also advocate having a conversation with your doctor at age 40 to discuss the benefits of annual mammograms for you.
What’s most important to keep in mind is that ALL of the medical organizations agree that women 40 years and older should at least initiate a conversation with their doctors about screening, and based on personal risk factors and the pro’s and con’s, decide what’s right for them.
Performing breast self-exams has also been questioned by some researchers because they are not considered an effective way to detect breast cancer. The sensitivity is low and often women become anxious about the lumpiness of their breasts. My advice is to try and do them monthly, because as I tell patients, no single method of detection is perfect. Every now and then, women can feel something that can’t be visualized on mammograms. The best time to perform a monthly breast self-exam is after your period starts, when your breasts are the “quietest.” If you’re in perimenopause and your cycle is not so regular or you are post menopause, try to pick the same time each month. The idea is for you to get comfortable with your breast exam and schedule an appointment if there is anything of concern that gets bigger, harder or does not move.
What Does Having “Dense Breasts” Mean?
Breast tissue is made up of milk glands and ducts, as well as some combination of fatty tissue and supportive tissues. There are four categories of breast tissue density: fatty, scattered fibroglandular, heterogeneously dense and extremely dense.
About 10% of women fall into the extreme categories of fatty and extremely dense, while the middle range categories each represent another 40% of the population. Therefore, about 50% of the population has “dense breasts” because they either have heterogeneously dense or extremely dense breast tissue. So you are far from alone if you have dense breast tissue.
The state requires us to inform women if they are considered to have dense breast tissue, so if you get a letter saying you have dense breast tissue, don’t be surprised and also don’t be alarmed. Having dense breast tissue does not directly increase your risk for breast cancer, but it does have an indirect effect on your overall risk. It makes it harder for us to see through the tissue and for you or your doctor to feel through the tissue, making it overall harder to find cancer. Therefore, there may be a slight increase in breast cancer risk the denser your breast tissue is. The letter is intended to make sure women are informed and can make the right decisions about the proper screening technique.
2D vs. 3D mammography
Knowing whether you have dense breasts becomes important when you are scheduling your mammogram. If you do have dense breasts, you should schedule a 3D mammogram, also known as tomosynthesis. 3D mammography allows a doctor to examine your breast tissue by layers because the machine takes multiple images of the breast to create a 3D picture. Atrius Health can offer patients the option of 3D mammography at any of our 5 imaging locations: Chelmsford, Somerville, Boston (Kenmore Square), Dedham and Weymouth.
That’s not to say everyone needs to have a 3D mammogram – those with non-dense breasts, for example, can have 2D mammograms after their first mammogram. 3D mammography has a few downsides, too, like longer compression time and therefore slightly more radiation.
Compression is already a reason many women cite for not wanting a mammogram at all. Compression is important because it helps separate the tissue so we can see through the breast tissue better. Even though it’s uncomfortable, it doesn’t last long.
Screening versus Diagnostic Mammograms
It’s equally important to know the difference between a screening mammogram and a diagnostic mammogram. A screening mammogram is meant to be used once a year if you have no issues – that is, if you haven’t felt anything unusual in your self-exams and you’re not being followed for anything. You come in, have your images, and leave. The report is sent to you in the mail.
A diagnostic study is when there is an area of concern: something you or your doctor feels or something seen on your screening mammogram. It’s very important to schedule a diagnostic appointment through your doctor’s office as soon as you detect a possible issue so that when you come in you are appropriately evaluated. A diagnostic exam is performed completely under the guidance of the radiologist. We review the images in real time and decide if we need to get more pictures or possibly add an ultrasound. You will get your results before you leave.
The good news is that most of the time when we find something it’s benign. We still may decide to do a follow-up diagnostic exam the next time (and often multiple follow-ups, meaning we will want to schedule diagnostic exams for the next 2-3 years). To be clear, following a finding over time doesn’t necessarily mean that there’s anything in particular of concern. We just want to make sure that what we’re following doesn’t change in a way that we’re not expecting.
An example is calcifications. Your body has calcium and it makes calcifications for a variety of reasons, most of which are benign. One common benign process is something called an involuting fibroadenoma. As the fibroadenoma disintegrates, it can calcify. Sometimes when you first see the calcifications, they look likely benign. However, we watch them to ensure they change as expected into a benign process. If things change in a way that we are not expecting, we may recommend a breast biopsy for further evaluation.
This is why screening mammograms every year are so important. Things change. You can have new findings or you could have a change in findings. As things evolve, we want to be there to catch anything that’s concerning as quickly as we can.
Detecting Breast Cancer
The research into breast health these days is very active, and that includes research into breast cancer as well. There has been a lot of news in the last few years about certain genetic factors. Please keep in mind that many women who have a strong family history don’t get breast cancer, and most women who get breast cancer do not have a genetic predisposition. Nevertheless, it’s important for us to know if you have a strong family history of breast cancer – that could include a first-degree relative, like a mom or a sister, who had breast cancer before the age of 50, or even a male relative with breast cancer, or if you have a lot of relatives who had breast cancer regardless of age – as we may refer you for a breast consultation with a specialist who can understand your history and determine your individual lifetime risk of breast cancer. Depending on what we learn, we can consider different options – for example, do you need additional screening regimens or more clinical evaluation, MRIs, or specific genetic testing? Because of new research and new technology, there’s more we can do to keep you healthier. If you have a known increased lifetime risk of breast cancer, you should re-visit the breast care specialist every 5 years or so to learn what new things are available to you.
If we see something in a mammogram or through an ultrasound and recommend you have a biopsy (where we take a sample of tissue from an area to see if they are possibly cancer cells), it doesn’t mean you automatically have breast cancer. It’s normal to be scared or anxious, and many women immediately go online. The American College of Radiology has a patient information website and is a good one to visit. Remember each person’s situation is very different and the large majority of women that we biopsy do not have cancer.
Biopsies in and of themselves are really straightforward. They’re done the same day under local anesthesia. I encourage you to eat and drink plenty of fluids. You can drive yourself to the appointment. Biopsies are usually pretty quick and we can talk you through the whole thing.
Even if you are diagnosed with breast cancer, I always tell my patients there’s a wide spectrum when it comes to breast cancer. Most patients, when they first learn they have breast cancer, immediately place themselves on the extreme, “worst-case” end of that spectrum. But there is a very wide range and many women can be treated successfully. I see many women who come back for their screening mammograms for years and years afterwards, cancer-free. It is important that women be consistent with their screening regimen so that any cancer that develops is discovered early, when we have the best chance for successful treatment.