Dear Doctor Keith: My girlfriends and I keep arguing over mammograms and when we should start getting them. I heard we don’t have to start until we’re 50, but my best friend said her doctor told her 40. What’s the deal?
–Cause for Concern?
Dear “Cause for Concern?”: Breast cancer screening has been a hot button issue over the last year. Many new guidelines have moved routine screening a full 10 years later than was previously recommended. Even though we as physicians know the evidence is strong in supporting these changes, it is hard to sell it to a population with personal experiences themselves, with a family member or with friends who were diagnosed at an age younger than the age recommended to even start screening. I personally have a sister and a friend in their thirties recently diagnosed with breast cancer and another friend recently diagnosed in her forties.
Let’s review the varying recommendations about mammogram screening, breast self-examination(BSE) and clinical breast examination (CBE).
The U.S. Preventative Services Task Force (USPSTF): This is the organization that initially kicked up the dust storm of controversy with its recommendations. USPSTF is an independent panel of primary care and prevention experts appointed by the U.S. Department of Health and Human Services to review the evidence for effectiveness of preventive services and make recommendations supported by research and clinical evidence. Their recommendations:
-Routine mammogram screening every two years for women between the ages of 50-74.
-Routine mammogram screening before the age of 50 should be a decision made between a women and her physician and all risks and benefits should be discussed.
-Routine mammogram screening for women 75 or older is not recommended.
-BSE is not recommended.
-CBE is not recommended.
-Magnetic Resonance Imaging (MRI) is not recommended (this is often used in conjunction with a mammogram).
The American College of Obstetricians and Gynecologists (ACOG): This is the organization that represents your OB/GYN doctors.
-Routine mammogram screening every year starting at age 40.
-CBE every 1-3 years for ages 29-39 and every year starting at age 40.
-No recommendation for BSE but promotes breast “self-awareness” (we’ll talk about that later).
The American Cancer Society: This is the well-known cancer society that attempts to raise cancer awareness, prevention, treatment, public policy and research.
-Routine mammogram screening yearly starting at age 40 and for as long as a woman is in good health.
-CBE every three years for ages 20-39 and yearly starting at age 40.
-BSE is an “option” starting at age 20 but also supports breast “self-awareness.”
Memorial Sloan-Kettering Cancer Center. This is a leading cancer center for research and treatment in the U.S.
-Routine mammogram screening every year starting at age 40.
-CBE annually starting at age 25.
-Promotes breast “self-awareness” but suggests monthly BSE starting at age 20 as an option.
With the above similar, but varying recommendations, it’s no wonder women seem confused and bewildered about what should be done when it comes to routine breast cancer screening. As an internal medicine physician and board-certified member of the American College of Physicians (ACP), we have worked hard at balancing the research conducted and the concerns of our patients. These are the recommendations I give to the patients in my Women’s Health Clinic and family members.
Routine Mammogram Screening:
-Every woman should have screening mammograms EVERY 2 years starting at age 50 until 74. More frequent screening leads to more false positives resulting in unneeded procedures that could have complications without increasing early detection or decreasing breast cancer deaths.
-Ages 40-49 and 75 or older, have a discussion with your physician about your concerns and ask about the benefits and risks of early screening and prolonged screening after age 74 and come to a consensus for the best option for you. Do not be afraid to ask for a second an opinion.
-This examination has not proven to increase early detection nor reduce bad outcomes associated with breast cancer.
-There is some evidence that CBE may act as an obstacle to getting a mammogram, which has proven benefits, as a normal CBE may give a woman a false sense of security leading to her postpone or all together forego mammogram screening.
-This is where some of the most confusion has arisen. The evidence is indeterminate about the BSE but there is strong suggestion that many of the early detections of breast cancer, especially in those too young to fall into routine breast cancer screening, occurs when a woman makes her physician aware of changes she has noticed. This is where “breast self-awareness” comes from. A monthly BSE can be part of this awareness, but I recommend that my patients sustain a conscious “identity” of their breasts starting at age 20. This means getting to now how your nipples look, the contour of your breast, the feel of your breasts and how the skin of your breasts look and being vigilant with noticing any changes that occur suddenly or over time. The most important changes to look for are:
-breast swelling (all or part, even without a detectable lump)
-skin irritation or dimpling
-breast or nipple pain
-nipple turning/pulling inward
-redness, scaling or thickening of the breast skin or nipple
-non-breast milk discharge from the nipple, especially if bloody
Any of these findings should be reported immediately to your doctor and followed by a CBE (this is different from screening as it will be focused on a specific complaint) and mammogram.
These are the guideline for routine Breast Cancer screening I recommend; however, there is a group of women who should consult their doctors about early and more frequent screening. Any women with a first degree relative, classified as a mother, sibling (yes, including brother) or even child, should contact their doctor immediately and get earlier screening. Any women with a direct relative with a genetic cause (i.e. BRCA gene mutations) for breast cancer should contact their physician immediately about screening and genetic testing options.
All this can, and is, very confusing in light of recommendations that seem to constantly change. Every woman should have an in depth conversation about her breast health with her physician and bring up any change to her breast as soon as they happen, and if ever unsure of the answers you receive, do not be afraid to ask for a second opinion.