Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
How frequently should women undergo mammography and breast examinations?
The American Cancer Society (ACS) recommends a baseline mammogram for
all women by age 40 and annual mammograms for women 40 and older for as
long as they are in good health.
In women with "lumpy breasts" or breast symptoms, and also in women with a high
risk of developing breast cancer, sometimes a baseline mammogram at 35 years of
age is recommended. This recommendation is somewhat controversial, and there are
other viewpoints.
However, the U.S. Preventive Services Task Force (USPSTF) issued new breast cancer screening guidelines in 2009, which recommend against routine mammography screening for women before 50 years
of age and suggests that screening end at 74 years of age.
The new USPSTF recommendations are in opposition to other existing breast cancer screening guidelines from organizations such as the American Cancer Society as described above. The USPSTF guidelines also recommend changing the screening interval from
one year to two years and suggest that women 40 to 49 years old who are at high risk for breast cancer consult with their doctor regarding the time to begin regular screening mammography.
It is important for women who are concerned about when to begin mammography to discuss the situation with their health-care professional. He or she can help you make an informed decision about breast cancer screening that is appropriate for your individual situation.
Mammograms and young women
There is a special issue regarding mammograms in young
women. Since young women have dense glandular breast tissue, routine mammograms
have difficulty "seeing through" the dense breast tissue. Therefore mammograms
may not be able to detect cancer in the breast because the dense breast tissue
around the cancer obscures it. However, this problem can be partly offset by the
use of special breast ultrasound, which is now
an extremely important additional imaging technique used to supplement
mammography in difficult cases. Ultrasound can make visible a lump hidden within
dense breast tissue. It may also detect lumps and early breast cancers when
mammograms fail to identify a problem. Ultrasound can also help doctors locate
specific areas in the breast for
biopsy (obtain small samples of tissue to study under a microscope). Sometimes
doctors also suggest the use of magnetic resonance imaging (MRI) screening
(see below) in younger women with
dense breast tissue.
Magnetic resonance imaging (MRI) scanning
Recent research has shown that MRI scanning may be a useful screening tool
for breast cancer in certain high-risk populations. In 2004, a team of Dutch
researchers published a study of over 1,900 women at high risk for breast cancer
in the New England Journal of Medicine. These women underwent breast cancer
screening that included physical exams every six months along with yearly
mammograms and MRI scans of the breasts. While conventional mammography did
detect many cancers at an early stage, some tumors were identified by MRI that were not detected by mammography. Overall, MRI led to the identification of 32 tumors, of which 22 were not seen on the corresponding mammogram. Likewise, some tumors appeared on mammograms that were not visible on the MRI scan. Mammography detected a total of 18 tumors, of which
eight were not identified by MRI.
The routine use of MRI, however, has many limitations. While it enabled the detection of some tumors in high-risk women, it also detected more noncancerous lesions (false-positives), which lead to many more follow-up examinations and potentially unnecessary medical procedures. In fact, MRI led to twice as many unnecessary examinations and three times as many unneeded surgical biopsies of the breast than screening by mammography alone. MRI is also approximately
10 times more costly (average cost $1000-$1500) than mammography.
Because of these limitations, experts believe that screening with MRI is impractical for women who do not have an elevated risk of developing breast cancer. However, its benefits appear to outweigh its limitations in certain high-risk populations.
In March 2007, the American Cancer Society Breast Cancer Advisory Group issued new breast-cancer-screening recommendations that include MRI scanning along with mammography for women 30-69
years of age who are considered to have an estimated lifetime risk of developing breast cancer of 20%-25%.
The previous screening recommendations regarding
breast self-examinations,
clinical breast exams, and mammograms were not altered in the 2007 screening
recommendations. Adding a yearly breast MRI was recommended for women who
have a BRCA1 or BRCA2 mutation, indicative of a strong inherited risk of breast cancer;
have a first-degree relative with a BRCA1 or BRCA2 mutation but have not been tested for the mutation; or
received chest radiation -- to treat Hodgkin's disease or other cancers, for example -- between 10 and 30
years of age.
The guidelines state that there is at present insufficient evidence to recommend the use of routine MRI screening in women with other risk factors, including a personal history of breast cancer, a history of carcinoma in situ or atypical hyperplasia, or dense breast tissue that makes the interpretation of mammograms difficult. Women with these risk factors may want to discuss their screening program with their physician to better determine whether MRI may be useful in their own case.
It is important to note that MRI should not be considered a substitute for regular mammography, and mammography is the only screening tool for which a reduction in mortality (death rate) from breast cancer has been proved.
Breast self-examination and breast examinations by your doctor
Both the American Cancer Society and the USPSTF do not call for regular self-examination of the breasts in their guidelines. The ACS states that breast self-exam is optional, while the USPSTF states that doctors should not teach women to do breast self-examination. The ACS further recommends a clinical breast exam (CBE) by a health-care professional about every
three years for women in their 20s and 30s and every year for women 40 years of
age and over.
The following technique describes the procedure for breast self-examination for women who choose this option.
How to perform a breast self-examination
Breast self-examination is best performed when the hormone stimulation of the
breast is the least. This typically occurs seven to 10 days after the start of a
menstrual cycle (or three days after a period). At that point, the fluid
retention of the breast and the cellular proliferation are the lowest. An ideal
setting in which to conduct the exam is the bath or shower.
With the hand and breast wet with soap, begin with
the fingers flat together and work sweeping from the outer part to the center
of the breast. It helps to mentally divide the area to be examined into
quadrants and work around the quadrants sequentially. The upper outer quadrant
should be
mentally extended into the armpit along the chest wall. This area should be
carefully included in the examination.
The process is repeated in the same sequence with the
fingers moving in a fluttering motion. These different motions, flat fingered
stroking and fluttering fingertips, allow detection of somewhat different
tissue abnormalities.
This examination by feeling the breast (palpation)
should be accompanied by a brief visual exam. With the arms at the side
looking in a mirror, note the symmetry. Then raise the arms slowly overhead,
checking for any areas of pulling in of the skin or visible lumps or distortion.
The entire examination process can be done in a few minutes' time.
Any detected change from the usual appearance or feel should be reported to
the doctor. If there are any areas of concern that can be felt (palpable) and
the mammogram does not show an abnormality, then a specialized breast ultrasound
can be extremely helpful.
For women who are concerned that they have lumpy breasts
and can't make any sense of their exam, it is best to do a careful exam after a
physician's examination. This serves as the baseline for normal "lumps." The aim is to maintain an appropriate degree of alertness
without creating continuous anxiety.
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