The Importance of Mammograms
There has been an increased awareness of breast cancer as well as screening in recent years. Screening is important because early detection, finding those small nonpalpable cancers can improve patient outcomes and save lives.
There have been multiple, perspective randomized trials that have shown that screening mammography can reduce mortality up to 40%.
Dr. Tamuna Chabra, a breast radiologist with the EvergreenHealth Breast Health Center, discusses the importance of mammography.
What is a mammogram like? There's a lot of women that are scared, so they don't know when they should start. There's a lot of confusion surrounding screening and even some controversy. Can you clear that up?
Dr. Tamuna Chabra: Our current recommendation is to start screening mammograms in average risk women starting at age 40 and to screen every year after that. And this is based on guidelines from the American College of Radiology (ACR) as well as the Society of Breast Imaging.
Screening mammograms should be relatively fast, they take about 15 minutes to perform. They should not be painful, although we do know that there is breast compression that's involved in order to acquire mammogram and it's essentially to immobilize the breast and it's similar to taking a photo.
If you are taking a picture, if there is any movement the image comes out to be blurry and the detail is lost. So, it is important to compress the breast and in order to acquire a good quality image.
Another point with compression is that with proper compression, it actually takes lower radiation dose to achieve proper exposure. So, that's another beneficial element to the patient when it comes to that.
You mentioned age 40. Are there any risk factors that would necessitate earlier mammograms, earlier screenings. What are the risk factors for breast cancer and just — I mean just every woman should have that mammogram starting at 40, but are there some who should start maybe at 35 or earlier?
Dr. Chabra: It's a great question. There are certain women that may have family history of breast cancer or may have some predisposition for breast cancer that may benefit from more what we call enhanced type of screening regimens and what that means is, starting them early as you mentioned and also employing and bringing in a supplemental screening tool such as screening MRI which is more sensitive in finding breast cancers especially in young women with dense breasts as well as high risk and high risk populations.
Based on current ACR guidelines, women that have lifetime of breast cancer greater than 20% which is considered high risk, women that may have genetic predisposition to breast cancer for example, BRCA gene mutation carriers and there are no tested first degree relatives to start screening mammography at the age of 30 and to start screening MRI between ages 25 and 29.
How can someone tell if they have an elevated risk?
Dr. Chabra: The risk is determined by what we call formal risk assessment which there are a multiple models out there that take into account patient's family history, reproductive history, history of previous biopsies whether it's benign or showing atypia and lifetime risk for breast cancer is generated for the patient. And that in turn will dictate what type of screening regimen may be appropriate for that patient and whether they may qualify for additional genetic testing.
We do perform this formal risk assessment for patients at the breast center. Referring providers can also perform that and we are actually in the process of forming high risk breast program at EvergreenHealth and we hope we'll be able to offer such service on a wider scale to a lot more patients and this is with the understanding that it is important to find the high risk patients, the high risk population especially when they are young, start screening young when it's appropriate so we can find those cancers earlier and improve patient outcomes.
As far as the technology goes, we've had these typical mammograms but now we have 3-D technology. Tell us a little bit about tomosynthesis and how is it different from conventional mammography?
Dr. Chabra: So, the 2-D mammograms are different from 3-D mammograms in a sense that with the 2-D conventional mammography, there is a single static image that's obtained per breast per view as opposed to with 3-D imaging, where we acquire multiple images maybe up to 15 or so per view. And this allows us to squall those images which brings out a lot more detail.
We are able to find smaller cancers, so this improves our sensitivity and also, we are able to appreciate things such as summation artifact or overlap of the tissue and this reduces our false positive rates. At Evergreen, we are 100% 3-D meaning that every single mammogram that's performed at Evergreen is done with tomosynthesis.
What about women with dense breasts? Does 3-D help with that to get a better picture?
Dr. Chabra: Yes, women with dense breasts, they probably benefit with tomosynthesis more so than women with for example with fatty breasts. So, the sensitivity is increased. As we know mammography is limited with patients with dense breasts, the sensitivity is not as high and tomosynthesis certainly proves that.
Do you need a referral for a mammogram?
Dr. Chabra: No, you actually do not need a referral for a mammogram. We have plenty of patients that come as self-referred patients and sine it's a screening exam that can be done without a referral.
When you look at the mammography scan, what you're looking for? Tell us what you do.
Dr. Chabra: As a breast imager, we read through the mammograms and look for signs of breast cancer.
Breast cancer can have different appearance in a mammogram. It can present a mass, possibly calcifications. So, we look for any small signs of breast cancer and if we do find it, then we require or advise patients to return for additional images which may lead to additional mammograms or ultrasound possibly subsequent biopsy which will lead to diagnosis of the breast cancer.
How long does it take to get the results? Women are also worried about that letter or about that phone call saying we need you to come back in. Explain about how the screening and diagnostic mammograms are different and what we are expecting as far as timeframes.
Dr. Chabra: We will read the screening mammograms at EvergreenHealth within several days. We then send the results to the patients in a letter.
If there is a finding that we see on a screening mammogram that requires additional attention; a patient will likely receive a phone call and that may lead additional mammograms or possibly an ultrasound as well just to do some troubleshooting and figure out whether the finding that was seen on the initial screening mammogram is worthy of biopsy or additional steps.
I would say that the majority of these call backs ask the patients to return for additional findings will be benign or probably benign findings. Oftentimes, we'll tell them to return back to screening and return in a year or sometimes, we may consider short term surveillance or have them come back in six months instead of a year to keep an eye on these probably benign findings.
What would you like women to know about mammograms to not be worried about them?
Dr. Chabra: With the screening mammograms, we detect — especially detecting those small nonpalpable cancers can really make a difference in terms of the outcomes and saving lives. So, it is important to obtain screening every year and it should not cause anxiety or pain.