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Breast Cancer Screening Guidelines: One Size Doesn’t Fit All

Conflicting advice from medical professionals and delayed preventative care during the pandemic are creating a perfect storm that may put millions of women at risk of delayed diagnosis, serious complications and death related to breast cancer.

Even Katie Couric, the former Today Show host who has long been known as the “Screen Queen” for her advocacy for colon cancer screenings since her husband’s death of the disease in 1998, wasn’t immune. After going two-and-a-half years between mammograms during the height of the pandemic, Couric was diagnosed with stage 1A breast cancer in June.

This year, during and following Breast Cancer Awareness Month, is an important time to further raise awareness about the impact of breast cancer and best practices for prevention and treatment. Let’s explore. 

A Pandemic Pause: Overcoming a Dip in Medical Screenings 

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Regular screenings for breast cancer are critical, as roughly 75% of the women who are diagnosed each year have no family history or genetic precursors of the disease. In fact, only as many as 10% of those diagnosed with breast cancer inherited genetic abnormalities from a parent.

During the pandemic, though, the number of mammograms declined as much as 80% at certain times, with breast-cancer screenings for low-income and uninsured women dropping by 87%. Putting off these regular screenings could result in nearly 2,500 additional deaths from breast cancer by 2030.

Conflicting Recommendations for Breast Cancer Screenings

Interestingly, there are differing guidelines regarding age, frequency of screenings and types of mammograms that have made women pause in proceeding with this preventative care.

The American Cancer Society recommends that by age 40, women should have the option to receive regular breast-cancer screenings, and by age 45 they should receive annual mammograms. The U.S. Preventive Services Task Force suggests mammograms before age 50 are an individual decision, and then are only needed every two years. The American College of Obstetricians and Gynecologists’ recommends offering mammography to average-risk women beginning at age 40 years and initiating screenings by no later than age 50 years.

A lot of components go into analyzing a woman’s risk for breast cancer, and it’s now recommended that any woman of any color is risk assessed no later than age 30. When it comes to risk assessing a patient to determine whether she is deemed “high risk,” (i.e., 20% or greater lifetime percent risk of breast cancer), many factors are considered, including:

  • Age: Generally, most subspecialty groups – such as the American College of Obstetricians and Gynecologists, American College of Surgeons and American Society of Breast Surgeons – recommend starting screenings at age 40.
  • BMI: Having more fat tissue can increase your chance of getting breast cancer by raising estrogen levels.
  • Age when first child was born: Women having their first child when aged under 18 years have only about one-third the breast cancer risk of those whose first birth is delayed until the age of 35 years or more.
  • Age of menarche and menopause: During women’s reproductive years, ovaries produce steroid hormones that directly affect development and function of the breast. Early menarche and late menopause are known to increase women’s risk of developing breast cancer.
  • Genetics and family history: Inheriting the BRCA1 and BRCA2 gene results in women having a 70% chance of getting breast cancer by age 80. There are also other less common genetic mutations like ATM, PALB2, TP53, CHEK2, PTEN, CDH1 and STK11 that increase risk as well. In addition, previous studies have reported that family history of colon, prostate and ovarian cancers has been associated with an increased breast cancer risk.
  • Race and ethnicity: Breast cancer is more prevalent in African-American women under age 40, particularly the less common triple-negative breast cancer.
  • Breast density: Dense, glandular and fibrous breast tissue increases risk of breast cancer and can make it more difficult to see cancers on traditional mammograms.

If a patient is deemed high risk, the recommendations by groups such as the National Comprehensive Cancer Network, American College of Radiology, and Society of Breast Imaging recommend even more differing opinions on screening. And if the patient is considered to be at average risk, then annual screening mammography beginning at age 40 is recommended by many other groups, including the American Society of Breast Surgeons and the American College of Surgeons. 

The last consideration is if a person is average risk with dense breasts, as many practices and institutions now offer supplemental screening in the form of ultrasound and breast MRI and, specifically as of late, abbreviated breast MRI – a study which is shorter than a full MRI but still demonstrates cancer-detection rates commensurate to a full MRI. In short, having the most up-to-date risk assessment tools are important to ensure women are being properly assessed and are receiving the correct imaging surveillance.

Improving Patient Care with Breast Cancer Technology and Best Practices

There are three approaches to mammograms. The most common are screening mammograms. These are the first lines of defense used to detect breast cancer in women who may not have symptoms. Then there are diagnostic mammograms, which are typically ordered when screening mammograms show abnormalities, or doctors see other signs of potential breast cancer. These mammograms, which offer a more detailed x-ray of the breast using specialized techniques, are also utilized if a patient has symptoms such as pain, a palpable mass, erythema (redness) of the breast or skin thickening.

And finally, there is 3D mammography, also known as digital breast tomosynthesis (DBT), which combines multiple breast X-rays from different angles to create a more detailed 3D picture of the breast. This approach enables radiologists to view the tissue in thin “slices,” minimizing tissue overlap that makes it difficult to distinguish normal breast tissue from tumors using traditional 2D mammography technology. 3D mammograms can be used for annual screenings and diagnosis to improve accuracy and reduce false positives; the greatest utility of DBT is its increased detection rates of invasive cancers and identifying tumors in women with dense breast tissue.

Today’s hospitals must consider that each mammography patient’s needs will differ greatly based on risk factors and past experiences, and that means being fully equipped to provide every woman with expert care, no matter the circumstances. It’s important that patients research the institutions performing their mammogram, asking whether they employ breast imaging specialists who read the mammograms and focus only on breast imaging interpretation. Having a designation from the American College of Radiology Breast Imaging Center of Excellence ensures that the center has been accredited by the highest standards of image quality, and a listing of those accreditations can be found on the ACR website

Furthermore, medical facilities should be regularly evaluating and testing their devices, and patients are within their rights to inquire about how frequently this is done. Ensuring that cutting-edge medical technology and protocols are in place and at a patient’s medical center of choice is extremely important. After all, when it comes to cancer detection, we are only as good as the equipment we have in many circumstances. Having those tools in our arsenal is imperative for the earliest cancer detection possible, such as identifying a subtle area of architectural distortion on digital breast tomosynthesis, which may not be seen on ultrasound, or identifying an invasive cancer on ultrasound that may be hidden on mammography due to the patient having dense breast tissue.

Ultimately, breast imaging specialists are in the business of saving lives. To do so, they simply need the best technology. Nothing less will do if professionals are to ensure cancer is detected at its earliest stage, thus maximizing the patient’s survival probability, requiring less invasive treatment and yielding positive outcomes as often as possible.

About the Authors

Dr. Amy Patel is the Medical Director of The Breast Care Center at Liberty Hospital, a breast imaging specialist, an assistant professor of radiology at the University of Missouri-Kansas City School of Medicine, and vice chair of the American Cancer Society-Kansas City Chairman’s Circle. She earned her medical degree from the University of Missouri-Kansas City School of Medicine, is board certified in diagnostic radiology by the American Board of Radiology, and is a Breast Imaging Fellowship Trained Radiologist through the Mallinckrodt Institute of Radiology. 

Morris Panner is the President of Intelerad Medical Systems, leading the company on delivering better care through improved technology. Morris served as CEO of Ambra Health from 2011 until its acquisition by Intelerad in 2021. Morris is an active voice in the cloud and enterprise software arena, focused on the services and healthcare verticals. He is a frequent contributor to business, healthcare, and technology publications. Previously, Morris built and sold an industry-leading business-process software company, OpenAir, to NetSuite (NYSE:N). 

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