Breast cancer screening is a personal experience. Breast tissue is different in every woman, compounded by differing medical histories and other risk factors – such as prolonged hormone exposure, family history of breast cancer, dense breast tissue*, previous biopsies, obesity, and diabetes. Given the many scenarios, a one size does not fit all for breast cancer screening.
Beyond regular mammography screenings, every woman should feel empowered to seek more information regarding her own personal breast cancer risk. It is important to engage your physician in a discussion that will help detect the earliest signs of cancer, when it is curable. Medical professionals recommend women at average risk get a mammogram every year beginning at age 40. Women with a higher risk of breast cancer should speak with their doctor.
Calculating your breast cancer risk:
To start, 86 percent of women want to know their breast cancer risk. A good, basic risk assessment tool for patient use is available on the National Cancer Institute website. However, your physician or breast-imaging center will also have assessment tools available during the screening process to help make a clinical decision based on your individual situation.
Patients can also assess their relative risk by looking at their breast tissue density as described in their mammogram report. Dense breast tissue on a mammogram is a risk factor for developing breast cancer, as well as the mammogram missing breast cancer, and warrants consideration for supplemental screening as outlined in an earlier post, “Reading Your Mammogram Report: Why Density Matters?” . “Heterogeneously dense breast tissue” may increase risk by approximately two-fold and “extremely dense breast tissue” may increase relative risk by 4-5 fold, or the same actual risk as a patient with family history of two relatives with breast cancer. Research shows that the higher the density, the greater the patient’s risk for developing malignancy, and those tumors detected in dense breasts are of increased size and worsened prognosis. Risk-based screening may identify high-risk women, prompt them to comply with annual screening if above average risk, and may be most effective if resources are limited. Unfortunately, risk models only have moderate discrimination, and may underestimate need for annual screening and for ancillary screening.
Below, I have outlined risk categories with my suggestions for screening – based on my knowledge as a fellowship-trained breast imaging radiologist, personal history of high-risk screening, and three generations of family members with breast cancer – to be discussed with your physician:
On average, the lifetime risk calculation for breast cancer is 15 percent. Standard screening is currently best performed with digital mammography, starting at age 40. Digital tomosynthesis / 3D-mammography, when available, improves detection of early breast cancer while reducing chances for false-positive callback examinations. Even with average risk – and no family history of breast cancer, the mammogram evaluates the potential additional risk factor of high breast tissue density, which may warrant additional screening with ultrasound or other available modalities.
For a high lifetime risk calculation of 20 percent or greater, patients do benefit from annual Magnetic Resonance Imaging (MRI) screening – performed at 6-month intervals after an annual mammogram -, as well as consultations for lifestyle changes that lower risk. (For example: exercise, weight loss, and good nutrition high in Vitamin D, resveratrol, and protein, while low in fat and alcohol). Patients testing positive for gene mutations warrant additional observation (more frequent and vigilant breast examinations, preferably by a breast surgeon), supplemental screening with MRI and Molecular Breast Imaging (MBI), and consideration for chemoprevention therapies.
MBI, which requires injection of a radioactively labeled tracer, is an ancillary modality that may elucidate cancer activity hidden in anatomically dense tissue.
Then, there are the intermediate 15-20 percent lifetime risk calculations which provoke anxiety, are unlikely to have an insurance-covered MRI (recent studies do demonstrate improved cancer detection rate at risk of false-positive findings), less incentive to improve lifestyle, and more reliance on the radiologist to recommend and perform additional imaging with Ultrasound, Contrast-Enhanced Digital Mammography (requires intravenous injection of contrast dye), or Molecular Breast Imaging. I recommend that women in this category sit down with their Breast Imaging Radiologist after a diagnostic mammogram (not a screening mammogram) to specify the best course for screening. Your radiologist can evaluate your breast tissue density and complexity, and then recommend their best available tool and interval for subsequent breast cancer screening.
In addition to one’s calculated risk category, patients with dense breast tissue should be considered for additional screening (after mammography or digital tomosynthesis/3D-mammography) with ultrasound. Alternatives include newer screening modalities (many that require intravenous access for contrast dye) such as contrast-enhanced digital mammography, abbreviated MRI, contrast-enhanced breast CT scans, and even MBI in complex cases. It is essential that you strongly consider with your physician the relative benefit of slightly more breast cancers detected at a risk of additional radiation exposure, possible biopsies, rare contrast dye reactions, and out-of-pocket costs.
My next post in this series will expand on the emotional considerations for breast cancer screening.
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