Get the Facts… and a Better Mammogram

Controversy about the value of mammography and different screening guidelines in the news have left many women confused; learn the facts about this important diagnostic tool.

By Elizabeth Chabner Thompson, MD, MPH

Every woman’s health profile is unique—a complex story of age, family history, genet­ics, lifestyle, and various other factors that combine to create a very individual pic­ture. Breast cancer risk is similarly unique: though on average one in eight women will develop the disease, this is only an average. An individual herself may have a much higher or lower risk.

Adding complexity to this issue of overall risk are conflicting recommendations for when to begin breast cancer screening. The US Preventive Services Task Force recommends beginning screening mammograms in asymptomatic women at age 50, whereas the Ameri­can Cancer Society recommends beginning at age 40.

Ultimately, early detection saves lives. Finding an early cancer or precancer dramatically increases sur­vival rates. Smaller tumors are easier to treat and af­ford patients more treatment options. Catching a can­cer early also decreases the likelihood that the cancer would have metastasized (spread).

Everyone should consider their unique medical his­tory and consult with their personal physician. At the most basic level, we can consider screening in two phas­es. First, in your twenties and thirties, perform a breast self-exam at home every month, and be sure to get a clinical breast exam as part of your annual physical. Be­come familiar with your breasts—the normal shape and contours—so that you can recognize what is new and different. If you notice something that does not seem right, even if you have just seen the physician, make a follow-up appointment.

Second, unless it is recommended earlier, once you hit age 40, begin receiving mammograms every one to two years at the radiologist’s office while continuing to perform self-exams and receive clinical exams at your annual visit with your primary care provider.

Understand the Diagnostic Technology

With new technology coming out every day, it is impor­tant to have a basic understanding of the different diag­nostic tests available so that you can not only know the right questions to ask but understand the answers and what to ask next.

  • Standard 2D mammography has been around since the institution of modern mammography in 1969. It finds calcifications and cancers of the breast 5 milli­meters or larger. For some women, such as those with breast implants, additional pictures may be needed and their mammograms need to be done by technicians skilled in techniques used for women with implants.
  • Digital mammography, also known as full-field digital mammo­gram, is fed into a computer so that it can be seen, shared, and stored digitally. The doctor can adjust the image size, brightness, and contrast to see areas more clearly. Digital im­ages can also be sent electronically for consultation.
  • Tomosynthesis turns digital mammograms into an image simi­lar to those of magnetic resonance imaging (MRI), which can detect cancers at a smaller size and an earlier stage. The pictures are com­bined into a 3D image that allows doctors to see problem areas more clearly. This approach will be the standard of care in a few years and is now available at cutting-edge medi­cal centers.
  • Doctors may use ultrasound to follow up a suspicious finding on a mammogram or for women with dense, cystic breasts. New technol­ogy combines tomosynthesis and ul­trasound to make detection of small cancers much easier.
  • For certain women at high risk, an MRI is recommended along with, or alternating with, a mammogram. MRI is not generally recommended as a screening tool by itself because, although it is a sensitive test, it may still miss some calcification that mammograms would detect. MRI may also be used in other situations, such as to better examine suspicious areas found by a mammogram.

Check with your insurance com­pany before having a test to find out what it covers. It can help to go to a center with a high-risk clinic, where the staff can assist you in getting ap­proval for a breast MRI.

Know What Your Doctor Is Looking For

Mammograms fall into two catego­ries: screening mammograms, which are used to look for breast disease in women, usually 40 years or older who are asymptomatic, with no breast problems, and diagnostic mam­mograms, which take more than two views in addition to magnification views. The diagnostic test is used to diagnose breast disease in women who have breast symptoms or an abnormal result on a screening mam­mogram.

Here are some of the changes that the doctor will look for when reading your mammogram.

  • Calcifications are tiny mineral deposits within the breast tissue that appear as small white spots on the films. They may or may not be caused by cancer. There are two types of cal­cifications:

o   Microcalcifications are tiny specks of calcium in the breast. They may appear alone or in clusters. Microcalcifications do not always mean that cancer is present or even that a biopsy (removal and examina­tion under the microscope) is needed. The shape and the layout of microcal­cifications help the radiologist judge how likely it is that cancer is present. If the microcalcifications look suspi­cious for cancer, a biopsy will be per­formed.

    • Macrocalcifications are coarse (larger) calcium deposits that most likely represent degenerative changes in the breasts, such as aging of the breast arteries, old injuries, or inflam­mation. These deposits are associated with benign (non-cancerous) condi­tions and do not require a biopsy. About half of women over the age of 50 and 10 percent of women younger than 50 have macrocalcifications.
  • A cyst is a fluid-filled sac that may be seen on a mammogram. Most cysts are benign, simple cysts that are not cancerous. Other cysts may contain cells within fluid-filled sacs; these are called complex cysts, which are often malignant (cancerous).
  • A breast mass (also called a growth or tumor) is an area that looks abnormal on a mammogram. Masses that are totally composed of cells are called solid tumors. Masses can be benign, such as a fibroadeno­ma, or malignant.

Often it is difficult to tell the dif­ference between a solid tumor mass and a cyst on physical exam or even a mammogram. An additional test called a breast ultrasound can help determine if an abnormality is a solid tumor mass, simple cyst, or complex cyst. A further test or biop­sy may be necessary to decide if the mass or cyst is benign or malignant. The physician might use a needle to aspirate (withdraw) fluid from a cyst and examine the fluid microscopi­cally for evidence of malignant cells.

Having your previous mammo­grams available for the radiolo­gist is very important to help show if a mass or calcification has not changed for many years. Your mam­mogram report may also contain an assessment of breast density, based on how much of your breast is made up fatty tissue versus fibrous and glandular tissue.

Dense breasts are not abnor­mal—about half of women have dense breasts on a mammogram. Although dense breast tissue can make it harder to find cancers on a mammogram, at this time experts do not agree what other tests, if any, should be done in addition to mam­mograms in women with dense breasts.

Take Steps to Ensure You Get a High-Quality Mammogram

For most women, making a mam­mogram appointment is about as fun as scheduling a root canal. The annual diagnostic test beginning at age 40 (or earlier, depending on your medical history and the advice of your physician) takes time out of your day and can be uncomfortable. And once you have the test, you can look forward to at least 24 hours of anxiety awaiting the results.

First, take a deep breath. Fewer than four screening mammograms out of every 1,000 lead to a cancer diagnosis. Early detection of a tumor is key to recovery. In fact, women di­agnosed with early-stage breast can­cer or pre-invasive breast cancer re­ceiving proper treatment have much greater odds of being cured.

Here is what you can do to make sure that you receive a high-quality mammogram.

  • Go to an established facility. Not all machines produce the same quality—some are old and give poor images. Ask about the age and the quality of the machine. Request to see the certificate from the federal Food and Drug Administration that ensures the facility meets high stan­dards of safety and quality.
  • Is there a doctor in the house? Ask if a radiologist is accessible. Having one available by phone helps speed up decisions to take either more views or views of different magnifications.
  • Ask around. Ask your friends and read reviews. Know who is in the mammogram room with you and write down their names just in case.
  • Be a repeat customer. If you are satisfied with the facility, go there on a regular basis so that your mammo­grams can easily be compared from year to year.
  • Bring pictures. If you are go­ing to a new facility, bring your old mammograms (or have them sent) and/or a list of the dates and places of previous mammograms, biopsies, or other breast treatments you have had.
  • Be aware of timing. Avoid the week right before your period, as your breasts can be tender and swol­len. Timing the mammogram for a couple of days into or immediately after your period is best.
  • Keep the lines of communica­tion open. If you felt a new lump, have a tender area, or have bleeding or discharge from your nipple, tell the doctor. Talk about any new or recurring medical problems you or your family members may have en­countered in the interim.
  • Come clean. Arrive at the radi­ology center with clean skin, par­ticularly breasts and armpits. Do not apply deodorant, antiperspirant, powder, or lotion, as these contain substances that can interfere with the reading.
  • Say no to the dress. Wear pants or a skirt to your mammogram so that you can have your bottom half covered and only your top exposed. The facility will provide a gown to cover your breasts.
  • Be a patient patient. There is often waiting time before they call you in to change for the exam; the mammogram it­self takes only about 20 minutes.
  • Expect a little discomfort. To get a high-quality picture, it is necessary to flat­ten the breasts. The technologist places the breast on the machine’s lower plate, then the upper plate is lowered to com­press the breast for a few seconds while the picture is taken. Count to five, and it will be over.
  • Wait for the verdict. By law, mammo­gram results must be shared with the pa­tient either through a phone call or writ­ten letter sent to her home. If you do not hear from your doctor within 10 days, call the facility.
  • Do not panic if you have to come back. Being called back occurs often. It usually means an additional image or an ultrasound is needed. This is more com­mon for first-time mammograms and then before menopause. Fewer than 10 percent of women who are called back are found to have breast cancer.

Elizabeth Chabner Thompson, MD, MPH, is a radiation oncologist, patient advocate, and medical entrepreneur. She earned her medical degree from Johns Hopkins University School of Medicine and her master of public health degree from Harvard University. As founder of BFFL Co, she develops products that improve the patient experience before, during, and after hospitalization in a way that preserves dignity and enhances recovery, including the Elizabeth Pink Surgical Bra.® Dr. Thompson is active in the Harvard School of Public Health Leadership Council, Johns Hopkins University Medical School Alumni Council, and Mt. Sinai Dubin Breast Center Advisory Board.