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Dr Orrange received her BA in Biology at the University of California San Diego and a Masters Degree in Health Sciences at the Johns Hopkins University School of Public Health She received her MD from the USC Keck School of…
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Breast ultrasound, mammogram, MRI or all three? Where are we now with Breast Cancer Screening?
As much as we hear about breast MRI and other new modalities for breast cancer screening it gets confusing for people to sort out what is best for them. To keep it simple, for most of us mammogram is still the best imaging study. Screening mammograms start for most women at age 40 and that's where the debate begins. Every year or every other year mammogram between the age of 40 and 50 depending on your risks, then at the age of 50 we all go to once a year mammogram. Let's start with the most common questions I am asked and get updated on the latest in breast cancer screening.
Which is better Digital or Analog Mammogram? Digital mammography has only been available at most facilities for the last 5 years. For most people the effectiveness is equivalent HOWEVER in pre-menopausal women, women with dense breasts, and women under 55 digital mammography fares better in the diagnosis of breast cancer.
What also matters with mammography? The person reading the mammogram matters! You want a radiologist who spends most of their time doing breast imaging. You can ask who is reading your mammogram and what percentage of their time they spend reading screening mammograms.
Who should get more than just once a year mammogram? ENHANCED SCREENING is recommended by the American Cancer Society for women at high risk for breast cancer. Women at high risk for breast cancer are:
- Those with the BRCA 1 or 2 mutation, or a first degree relative with BRCA 1or 2 mutation and not tested
- A Lifetime risk of breast cancer 20% or greater
- Radiation to the chest between the ages of 10-30 years
How do I find out if I am considered high risk? You can assess your risk using a well known risk assessment tool. It is published on The National Institutes of Health website (http://www.cancer.gov/bcrisktool/Default.aspx) and this will give you your risk for the next five years. Always discuss your results with your healthcare provider as well.
Who should be tested for BRCA 1 and BRCA 2? These are the inherited mutations in the genes that are involved in hereditary forms of breast and ovarian cancer. The US Preventive Services Task Force recommends screening for BRCA 1 and 2:
- Those with known family members with BRCA 1 or 2 mutations,
- Known Ashkenazi Jewish Heritage WITH one first degree (mom, sister) or two second degree relatives with breast or ovarian cancer. Additionally
- Two first degree relatives with breast cancer, of whom one received the diagnosis at 50 or younger.
- One first degree relative with bilateral breast cancer regardless of age of diagnosis.
- A combination of three first or second degree relatives with breast cancer regardless of age of diagnosis.
- Breast cancer in a male relative
- A combination of breast and ovarian cancer among first and second degree relatives, or 2 or more first or second degree relatives with ovarian cancer.
Is it better to get an ultrasound and a mammogram together? This question was asked and answered in a study published in 2008 which looked at screening ultrasound + mammography vs. mammography alone for certain women at risk for breast cancer.
How was high risk defined in this study? BRCA 1 or 2 (+), history of chest, mediastinal or axillary radiation,25% lifetime risk of breast cancer or 5 year risk > 2.5% or > 1.7% and extremely dense breasts. Women with a personal history of breast cancer, atypical ductal or lobular hyperplasia, DCIS, or lobular carcinoma in situ were also included.
What did they find? The good news was that adding a SINGLE screening ultrasound will detect 1.1-7.2 additional cancers per 1000 women with increased breast density. The bad news was this study used physician-performed ultrasound so it s not clear if the results would be the same with non-physician technicians. The other bad news was that the number of false positives increases with ultrasound which results in unnecessary biopsies.
Conclusions about Breast ultrasound + Mammography for screening in high risk women: When physician performed, breast ultrasound increases sensitivity but decreases specificity of cancer screening in high risk women with dense breasts. No guidelines currently recommend screening breast ultrasound.
What about Breast MRI? For those who need "enhanced screening" (criteria listed above) annual screening MRI as adjunct to mammography and clinical breast examination is recommended. Again, there is insufficient evidence for or against the addition of screening ultrasound.
To summarize about Breast MRI (since I am asked about it quite a bit) Current guidelines recommend MRI with mammography in some high risk women. There are no studies of the effect of screening breast MRI on breast cancer mortality that have been published as of yet. Routine breast MRI in everyone is NOT recommended because of the high false positive rates and unnecessary biopsies, in addition to being very expensive. Again, breast MRI is recommended in combination with mammography in women at very high risk of breast cancer.
What about for women with saline or silicone implants? There is still no evidence to suggest that any screening test is better than digital mammogram for those with implants. For questions of whether an implant has ruptured MRI is helpful.
Thoughts? Experience?
Dr O.
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Displaying comments 27-8 of 27
Got a Question?
My mom,2 of her sisters and a Great Aunt on my mothers side,all had breast cancer.
A lump was found in my right breast at age49.A biopsy revealed it to be an LCIS (do I have the terminology correct).Anyway,a pre cancerous growth.
With my family history,and finding I had BRAC 1 BRAC 2 Gene,I opted to have a phrophalatic Dble mastectomy.
I felt it was the logical choice,instead of mamograms every 3 months,and even then the chance of it sneaking up on me wasn't a pleasant thought.I didn't want the specture of breast cancer hovering over my everyday life.
So now,I never have to worry about breast cancer.
I'm not entirely pleased with reconstruction,done with saline inflatable implants.....I think the plastic surgeon wasn't really straight forward with how they could turn out looking ,not really like breasts at all.
Medusa08: You sound like you have fibrocystic breast changes which are VERY common and digital mammography tends to be better than analog for you..so find a place that can screen you with a digital mammogram. Implants are fine and you can still get screened for breast cancer even with implants.
Kandyland2001: not only can you ask for early screening but you can ask for BRCA testing given that your mom had BILATERAL breast cancer. Find a breast surgeon near you for appropriate testing and screening if your primary care doctor can't take care of if for you.
DR O.
Thank you,
Christinadukie@yahoo.com
I have not had a mammogram in 3 years since after my divorce and move from the small town I lived in. I need to have a mammogram badly, since I remember my previous Dr. said that I had cystic breasts for the past 15 years. Nothing came up positive for cancer and just water and vitamin E was reccommended, not much caffeine, and also I am sup. to have a mammogram every 6 months. I am almost 50. 1)Am I not at risk having cystic breasts, 2)is that the same as having dense breasts, 3)can I have breast implants with cystic breasts (smaller implants), and 4)what type of mammogram is good for cystic breasts?
Thank you, Dr.
> By the way: June is Men's Health Month.
Thank goodness. I'm sick of one group over the other competing for attention and saying they are not equal when they many times have always been more than.
Men ARE more important* than women they do more and complain less, they should be given more funds and consideration for all their needs.
* they are stronger
* they are more beautiful
* more polite
* more intelligent
* etc.
: )
By the way: June is Men's Health Month. Will you be focusing on men's health next month, Doctor O?
Contact: Susan Mosychuk (202) 225-2301
Murphy Brings Men’s Health Issues to the Federal Stage
Drafts Bipartisan Legislation to Create Office of Men's Health within HHS
Washington, Thursday, April 30, 2009 -
Congressman Tim Murphy (R-PA) and Congressman Barron Hill (D-IN) today introduced H.R. 2115, the “Men and Families Health Care Act of 2009.” This bipartisan legislation would establish an Office of Men's Health within the Department of Health and Human Services for the purpose of improving the health of men and their families in the United States. This Office will mirror the existing Office of Women’s Health, established in the early 1990s, which has improved the quality of life for women nationwide.
“The goal of this bill is to raise awareness about men’s health issues, and ways we can prevent and detect men’s health problems. The Office of Men’s Health will bring this issue to the federal stage and result in more men getting the treatment they need, which will save lives,” said Congressman Murphy. “For too long the health needs of men have gone unaddressed. This bill will help men’s health take its rightful place in our federal government’s healthcare priorities.”
“I try to take good care of myself by exercising and watching what I eat. But, I know I need to go to the doctor more often. I think men often need a little extra push when it comes to taking care of their health, and I think this bill is one way to do just that,” said Congressman Hill.
The office will be designed to monitor and coordinate efforts to improve the health and well-being of men by streamlining government efforts on the federal and state levels in the areas of prevention, health education, outreach, and research. You can learn more and take action by visiting the Men’s Health Office Resource Center at www.menshealthoffice.com
Dr O.
However, the location was too far fom my home for me to be able to attend.
I'm disabled, you see, unable to walk more than a few yards.
To get to the clinicwould have involved a four bus journey, which I wasn't able to undertake.
I phoned thre clinic, asking if it would be possible for my appointment to be re-scheduled to a day when my husband was off work and would be able to drive me......
It wasn't possible.
Ergo, I had to cancel the appointment and won't be eligible for another for three years.
I'm not convinced of the efficacy of mammograms, anyway, since a friend was given the all-clear, yet died of a carcinoma that couldn't have been detected by mammogram.
Thanks so much for your article. Considering I am pre-menopausal, have had radiation treatments to the neck and chest, breast densness, and come from a known background of the Ashkenazai Jewish tribe, (I have Gaucher's disease), this was a very appropriate article. I am calling the OBGYN to get a mamogram and testing for BRCA 1 or 2 in the morning.
You may have saved my life.
Doalan: When have I ever made a point that it is "wrong when the attention is skewed toward men but justify it when it is skewed toward women."
Andromeda7: Some receive their first baseline between the age of 35 and 40 but for most who are low risk the recommendation is for your first annual screening mammogram at 40...assuming you have been receiving annual breast exam.
Tadlem: Great point about breast self exam...because most early breast lesions are NOT paplable on breast self exam it is most important in women under 40 who are not yet getting annuals. Also evidence has shown that breast self exam twice a year is equivalent to monthly.
Breast cancer is rare in men and annual screening mammogram is not recommended. Breast self exam in men (and your doctor can do this annually) is recommended as men can more easily palpate a nodule or abormality given they dont have the fatty tissue women have.
Calcifications are common and your radiologist will decide if they find them worrisome (worth a biopsy) or are stable and unchanged...that is where a good radiologist and close follow up is helpful.
For those after breast reduction surgery it is still recommended the first line screening test is mammography.
In premarketing studies on continuous oral contraceptives there was not an increase in mammogram abnormalities or breast atypia or cancer.
Dr O.