How frequently should women undergo mammography and breast examinations?
The American Cancer Society (ACS) recommends that all women begin having yearly mammograms by age 45 and have mammograms every other year (or keep having them yearly) beginning at age 55. The ACS also recommends that women should have the choice to start having yearly mammograms as early as age 40 if they want to do so.
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 an earlier age is recommended. This recommendation is somewhat controversial, and there are other viewpoints.
However, the U.S. Preventive Services Task Force (USPSTF) recommends against routine mammography screening for women before 50 years of age and suggests that screening end at 74 years of age.
The 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 a screening interval of 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 their patient make an informed decision about breast cancer screening that is appropriate for their 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
Research has shown that MRI scanning may be a useful screening tool for breast cancer in certain high-risk populations. 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 surgeries. 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 $1,000 to $1,500) 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.
The American Cancer Society recommends that women at high risk for breast cancer (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15%-20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening.
Women at high risk for developing breast cancer include those 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;
- received chest radiation -- to treat Hodgkin's disease or other cancers, for example -- between 10 and 30 years of age; or
- have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes.
Women with significant 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 proven.
Breast self-examination and breast examinations by a 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. Studies have not shown a clear benefit of regular physical breast exams done by a health professional (clinical breast exams) or breast self-exams. There is very little proof to suggest that these tests can help detect breast cancer early when women get screening mammograms. However, women should be familiar with how their breasts normally look and feel and report any changes they notice in their breasts to a health care provider.