The lifetime risk of breast cancer for women is 1 in 8, or about 12%. This is for the average risk person, not someone who has a genetic syndrome or predisposition to breast cancer.
Since October is Breast Cancer Awareness month, this seems like the obvious topic this week.
We’re all accustomed now to seeing pink ribbons decorating businesses, buildings, food items, and even NFL players.
To me this almost seems to be an awareness of a symbol, not necessarily what we can choose in our lives regarding the disease.
What can we do to be accountable, not just aware, of the choices we can make regarding this disease?
The first is knowing our risk factors for developing breast cancer. Some of these we can choose, others we cannot.
Age
Age of first period (earlier than 12 is higher risk)
Age of first pregnancy (after 30 is higher risk)
Family history (important - but not everything)
Alcohol use (over the “limit” of one drink per day)
Diet
Lack of breastfeeding (I’m not aware of a duration that has been shown to be protective, but I have seen some quotes of 6 months)
Dense breasts
History of breast biopsies
Dense breasts is a relatively newer risk factor and awareness in the general public. First, many patients have access to online portals where they can see test results from their doctor. If you have this, you will now see on your mammogram report some words regarding the density of your breasts. This is because the FDA mandated that breast density is reported. Why? Breast density has been shown to be a risk factor for breast cancer. Mammograms also don’t perform as well as they do for someone without dense breasts.
There are four categories of breast density:
Predominantly fatty (this is the least dense)
Scattered density
Heterogeneously dense
Extremely dense (this is the most dense)
From top to bottom, or least dense to most dense, the sensitivity (the ability to rule out disease) of a mammogram goes from 90% to about 60%. This is, as of right now, still the best test we have for detecting cancer. There are ongoing studies about adding MRI to the general screening protocol for people with dense breasts or everyone. As more literature is available, I will update.
When should screening begin, how often should it be done?
I frequently have this conversation with patients and I frankly tell them that the recommendations will differ depending on which society you follow. That is astounding to me. With the exception of one society (USPSTF), societies otherwise agree that screening should start at age 40. The reason for this is that most lives are saved when screening starts in the 40s.
Recommendations will differ as far as doing mammograms annually vs every other year. This may also come down to insurance coverage, as some may not pay for an annual test.
I have patients with reservations about the radiation risk, especially with doing the test every year. The radiation risk is less than what we are exposed to in a year as humans on Earth, less than a CT scan if you’ve ever had one of those.
I try to individualize the timing based on the patient age and her risk factors. In a relatively low risk patient in her 40s, if she has reservation about radiation exposure, it may be reasonable to do the mammogram every other year. I do recommend annual tests after the age of 50.
I had a patient yesterday with concerns about this. She ultimately decided to pursue the annual mammogram (she is over age 50). Her reasoning was that the risk of the test was lower than the risk of having a cancer go undetected for another whole year.
Another risk of the test itself is the potential for a false positive, or being called for additional studies when actually there isn’t anything concerning there. This can be stressful and anxiety-provoking to a patient.
When should we stop doing mammograms?
According to the American College of Radiology, there is no established age to routinely stop doing mammograms. This should be individualized depending on the patient’s health, family history, and desire for screening. The American College of Obstetrics and Gynecology leans toward age 75, with the caveat that screening can continue if the patient is healthy and wants to continue.
Ultimately, choosing to be tested, how and when, is your choice as a patient. This is usually complicated by insurance coverage, unfortunately. The point is that I discuss choices with my patients with their best interests in mind. Especially in this case, the societies all have different recommendations (again, all but one recommend starting at age 40) so there is some wiggle room for decision-making in my opinion.
Resources:
Some of the information contained in this course is the result of my training, medical knowledge, and personal experience without a specific source to be cited.
https://www.acr.org/-/media/ACR/Files/Radiology-Safety/Radiation-Safety/Dose-Reference-Card.pdf
Disclaimer: This is descriptive, not prescriptive. This is not medical advice. You are an individual and should discuss with your provider.
