•    It matters who reads your mammogram. If your study is read by a radiology doctor (radiologist) who practices general radiology or another radiology subspecialty and only reads a few mammograms per week, you are probably not receiving the best care. Yes, the guy is board certified and is licensed by law to read your mammogram. But I am licensed to read all radiology studies as well, even though my specialty is breast imaging. Doesn’t mean I should muddle through interpreting the next brain or shoulder MRI that comes my way. Thinking about it now, I am “qualified” to read Peyton Manning’s next MRI of his neck. Do you believe that anyone in their right mind would let me do this? My point: You and your life are just as important as the talented Mr. Manning’s career. Don’t settle for less than the best.
     A well-done study published several years ago proves and quantifies this point. The link to the journal article is here. The researchers found that specialty-trained breast radiologists find significantly more cancers, and at earlier stages, than the general radiologists.

•    Yes, it matters where you choose to go for your mammogram! The most basic requirement is whether a facility is accredited under the MQSA (Mammography Quality Standards Act). The accrediting body for most states is the ACR (American College of Radiology), which has a list of requirements and tests that facilities must comply with in order for the centers to achieve accreditation. They look at things such as equipment and film quality, radiation dose, credentials of the mammography technologists and of the radiology doctors who interpret the films, quality of reporting and follow-up, etc.
     The ACR has a convenient webpage for you to search for accredited facilities in your vicinity.
     When you see the results of your search on the ACR site, look for this badge next to the names of the breast centers on your list:
  
     This symbol means that the center has jumped through many extra hoops to attain status as a “Breast Imaging Center of Excellence.” My own practice in New Jersey has been designated as a Center of Excellence, after a lot of work by many people. It’s worth your while to go to one of these centers if it’s practical for you, depending on where you live and how far you are willing to travel. It can make your life easier down the line because if you ever need to have additional testing or a needle biopsy, these centers can handle it and won’t need to send you elsewhere. At the very least, these facilities have demonstrated their commitment to their patients by dealing with the bureaucracy and mounds of documentation necessary to achieve this special status. It’s not a guarantee of higher quality, but it’s a good sign.

•    Never ignore a lump. When you feel a lump and mammogram and ultrasound (also known as a sonogram) are negative, there is still a 2-3 % chance that the lump is cancer. Have your doctor refer you to a breast surgeon. They might want to perform a needle biopsy in the office based on what they feel, or they may advise surgical removal of the lump in the operating room. If the doctor doesn’t test the lump, and you still feel it, seek a second opinion from another surgeon. You know your body better than anyone.

If I am at high risk for breast cancer, what imaging tests should I be having each year, starting a what age?

•    If you have a strong family history of breast cancer (mother or sister premenopausal), start having your mammogram 10 years younger than the age that relative was diagnosed, OR at age 40, whichever is younger; but not before age 25. For example, if your sister had breast cancer when she was 44, you should start having your mammogram at age 34. If your mother had breast cancer at 60, you would start having your annual mammogram at age 40, with perhaps a baseline mammogram at age 35.
     If you or your mother or sister have been diagnosed with the breast cancer gene (BRCA1 or BRCA2) you should begin having annual mammograms at age 25, and annual breast MRI sometimes even younger than 25. Your breast doctor should advise you on this.
     If you have had Hodgkins disease (lymphoma) in the past, and were treated with radiation to your chest, you should start having annual mammograms 8 years after your treatment was completed. You should also be sent for yearly breast MRI. If you have history of atypical ductal hyperplasia or lobular neoplasia on a prior biopsy, we recommend doing annual MRIs in addition to mammography.
     At my practice, we recommend annual mammography and MRI for anyone who has a personal history of breast cancer. This issue is being actively studied and discussed at radiology conferences; our opinion is that there is plenty of evidence to support this recommendation.

Why are there laws in some states regarding women receiving their breast density information?

•    A wonderful grass-roots organization has been founded by women personally affected by the lack of information given to them regarding the density of their breasts (www.AreYouDense.org), and they are doing everything they can to address this issue for all women. Because of their advocacy, laws have recently been passed in Connecticut, Texas, Virginia, New York and California, requiring that women be informed of their density when they have a mammogram. Bills are also active in several other states, as well as at a federal level. Two of our surgeons at Montclair Breast Center testified in front of the New Jersey State Senate Commerce Committee, where a bill was unanimously approved to move to the next step in the process of becoming a state law. Unfortunately, because of strong lobbying by health insurance companies, the bills (except in Connecticut) have been watered down and do not include the mandate that patients’ insurance companies cover the cost of second-level screening tests for women with dense breasts. Hopefully, with enough pressure from the 40% of women with dense breast tissue, this situation will change in the future.

•    Don’t be surprised if your doctor does not know much about breast density. As the issue gains traction, the medical community will become more informed over time. For now, it is up to you to find out if your breasts are dense so you can protect yourself from advanced cancer.
     Your density information should be in the official report from your mammogram, so ask your doctor for a copy of this report. Do not rely on the form letter you receive from the mammography center; this will not include your density (unless you live in Connecticut, Texas, Virginia, New York or California. And hopefully soon in New Jersey). If it’s not in the official report, call the radiologist who read your films and ask them. It might take some legwork, but you have a right to know this!

•    Breast density is one of the strongest predictors of the failure of mammography to detect cancer. About half of women younger than 50 are dense, and 1/3 of women over 50 are dense. Up to half of breast cancers cannot be seen on the mammogram in women with dense breasts. This leads to missed cancers that are discovered at later stages, resulting in more invasive treatments and a poorer prognosis. 40,000 women in the U.S. die each year from breast cancer. Some of these women had dense breasts and didn’t know it; even though they went for mammograms every year, by the time their cancers were found it was too late.
     Density is determined by a mammogram. It cannot be determined with physical exam. Dense breasts have more fibrous and glandular tissue (which appears white on the films and can hide cancers, which also appear white), while breasts that are NOT dense have more fatty tissue (which appears grey and is easy to see through on the mammogram).

If I have a negative (normal) mammogram, does that mean I definitely don’t have breast cancer?

•    Mammography is an imperfect test. A “normal mammogram” report does not mean that a woman does not have breast cancer. Overall, mammograms will pick up 80-90% of cancers. That’s pretty good, but there are still 10-20% of cancers that will not be seen, and will present as an “interval cancer” with a palpable lump.
     The cancer detection rate plummets in women with dense breasts to only 40-50% of cancers picked up on a mammogram. This is why it is so important to know if your breasts are dense. Knowing the imperfection of mammography also underscores the importance of a yearly physical breast examination by your doctor, and the importance of doing your own monthly breast self-exams. Women find many cancers on their own. If you think something is wrong, trust yourself. And seek a second opinion if your doctor dismisses your concern.

At what age should I start having screening mammograms, and how frequently? Why does there seem to be controversy in the media surrounding this?

•    For most women, age 40 should be when you start having yearly mammograms in order to minimize your likelihood of developing advanced breast cancer. Some doctors send their patients for a baseline mammogram at age 35, and I wouldn’t argue with that.
     If you have a strong family history of breast cancer (mother or sister), start having your mammogram 10 years younger than the age that relative was diagnosed, OR at age 40, whichever is younger. For example, if your sister had breast cancer when she was 44, you should start having your mammogram at age 34. If your mother had breast cancer at 60, you would start having your annual mammogram at age 40.
     If you or your mother or sister have been diagnosed with the breast cancer gene (BRCA1 or BRCA2) you should begin having annual mammograms at age 25, and annual breast MRI sometimes even younger than 25. Your breast doctor should advise you on this.
     If you have had Hodgkins disease (lymphoma) in the past, and were treated with radiation to your chest, you should start having annual mammograms 8 years after your treatment was completed. You should also be sent for yearly breast MRI.
     As to the second part of the question: The United States Preventive Services Task Force (USPSTF), a panel appointed during the George W. Bush Administration and supported by the federal Agency for Healthcare Research and Quality, a branch of the U.S. Department of Health and Human Services, issued recommendations regarding breast cancer screening in 2009. This panel consisted of physicians in primary care (internists, pediatricians, Ob/Gyns), nurses, epidemiologists, biostatisticians, and public policy officials. Not one single breast cancer expert (breast surgeon, oncologist, radiologist, radiation oncologist) was included at the table, and there was neither invitation nor opportunity for breast cancer experts to address the panel before the recommendations were handed down. The panel recommended screening mammograms every other year, beginning at age 50; this was a significant departure from the 2002 USPSTF recommendations, which called for annual screening commencing at age 40. Incredibly, the panel also recommended that women should not be taught or encouraged to do breast self-examination, and that physicians should not perform clinical breast exams on their patients to check for cancer. Instead of being applauded as one of the few interventions in the healthcare system that actually saves people, with a 30% reduction in breast cancer mortality in the U.S. since 1991, breast cancer screening was under attack.
     To support its proclamations, the panel used a computer model to create new, non-peer-reviewed data extrapolated from previously published studies on mammography screening. Some of these papers were decades old. The USPSTF used the lowest estimate of mortality reduction attributed to mammography (15%) among the various numbers that exist in the literature (as high as 54%). Even with their selective use of a low mortality reduction figure to create their new numbers, the USPSTF’s own “data” confirmed that significantly more women would survive if mammography screening began at age 40. But they ignored their own data, and they claimed that the supposed “harms” of screening (discomfort, anxiety, being called back for additional pictures, potentially having a needle biopsy that turns out to be benign, the risk of diagnosing cancers that wouldn’t necessarily kill the woman— though no one can tell us which cancers those are at the current time) outweigh the benefit of lives being saved. This was clearly not an objective, impartial scientific judgment; this was a value judgment, made with the over-arching goal of creating cost-saving public-policy recommendations for a broken healthcare system.
     My advice? Start annual screening mammography at age 40; earlier if you are high risk; have a baseline at age 35 even if you are not considered high risk. The single most common cause of death among women age 35 to 50 is breast cancer. If there is any time to screen for it, it is during those years, the prime time of your life, when there are many people who need you to stick around.

What is a digital mammogram? Is it more accurate?

•    The traditional mammogram was a film-screen, or analog, mammogram. In 2000, the FDA approved the use of digital mammography units. An x-ray is still taken, but instead of the beam being directly translated onto a film, the beam is converted to digital data that is then processed to appear on a computer monitor. The digital image can be manipulated on the computer screen, with tools for magnification, contrast and windowing adjustments, sharpening, etc. Approximately 80% of the mammography units in the U.S. are now digital. The radiation dose is lower than film-screen mammography, and a large-scale study showed somewhat better cancer detection in dense breasts. If you have a choice between a digital or a film-screen mammogram, go for the digital.