Last updated: Mar 18, 2010
breast-cancer-screening

For years, Id written about breast cancer from every possible angle. Then, all of a sudden, I was living it. My aunt and mother were diagnosed 15 and 8 years ago, respectively, and then my aunt got ovarian cancer as well. To confirm my suspicions of a family connection, I got tested for the BRCA genetic mutations. I did, indeed, have BRCA1 and what comes with it: a roughly 60 to 80 percent lifetime risk of one day developing breast cancer and a likewise-inflated risk of getting ovarian cancer.


I was determined to take some control. In 2007, I wrote in the pages of Health about having my ovaries removed, but I wasnt ready to even consider parting with my breasts. Instead, I went the surveillance route, trembling before every mammogram, undergoing magnetic resonance imaging (MRI)–guided biopsies, ultrasounds, and one surgical biopsy, all of which found nothing. As time went on, though, my D-cups felt more and more like time bombs, so last fall I decided to book a prophylactic double mastectomy—to save myself some psychic stress.

Coincidentally, just as I was setting up my surgery, the U.S. Preventive Services Task Force (USPSTF) announced a controversial set of guidelines for women, including that age 40 was too early to begin routine mammograms (for average-risk women, anyway). The new recommendations, which Health wrote about last month, caused women their own psychic stress, because they flew in the face of what wed all been told for years. I took the information I had and made some decisions, but many women were left with more questions than answers.

To help you figure out how best to take care of your breasts, we corralled the nations top experts and asked them the questions youve told us are on your mind. Cant find all your answers here? Bring this story to your next checkup to help you work out a plan of action.




1: Im confused—what happened to the universal recommendation that every woman should start routine mammograms at 40?

Of course youre confused. That advice had become conventional wisdom for the early detection of breast cancer. The thing is, while mammograms reduce the risk of dying from breast cancer, the task force also weighed the downside to screening women of average risk in their 40s.

They couldnt ignore the numbers: For every woman whose life is extended by starting screening at age 40, about 1,000 women will have a false-positive mammogram, explains Russell Harris, MD, a USPSTF panel member and a professor of medicine at the University of North Carolina.

False positives are scary and lead to more tests and biopsies, and mammograms may lead to treatment of breast cancers that dont need to be treated. For most women in their 40s, the guidelines suggest, the downside of following up on what is highly unlikely to be cancer may be greater than the small chance of finding a cancer early.

2: But what if youre one of the few women whose life would be saved by a mammogram in her 40s?

No one can guarantee that you wont be, and breast cancer in younger women tends to be more aggressive. Whether to start getting screened in your 40s comes down to your comfort with risk. What researchers know for sure is that most breast cancer is found in women older than 50 and that its critical to be aware of your risk factors.

For that, talk to your doctor. “Id caution a woman that its nearly impossible for her to calculate for herself if shes at average or high risk,” says Christine Laronga, MD, program leader of the Comprehensive Breast Program at the Moffitt Cancer Center in Tampa, Florida.

3: So should I get mammograms starting at 40 or not?

If you are at high risk, yes, start getting them at 40 (or even earlier). Assuming youre at average risk, you should do what feels right.

“If youre OK with the possibility of false positives and the anxiety that may go with it, you should go ahead and get your mammograms in your 40s,” says Laura Esserman, MD, director of the Carol Franc Buck Breast Care Center and professor of surgery and radiology at the University of California, San Francisco. But if you think the worry would be too much for such a small likelihood that you have breast cancer, then you might want to hold off.




4: How do I know if Im high-risk?
For younger women, “Family history and BRCA mutations are the most telling risk factors,” says Richard Shapiro, MD, associate professor of surgery at The Cancer Institute at the New York University Langone Medical Center in New York City. Heres why, below, as well as the other important factors to discuss with your doctor:

  • Genetic mutations, like BRCA1 and BRCA2. While Ashkenazi Jewish women are around five times more likely than the general population to have one of the BRCA mutations, according to the National Cancer Institute, Norwegian, Dutch, and Icelandic women also have higher frequencies than most. Still, no ethnic group is totally exempt, so if youre concerned, book a meeting with a genetic counselor.

  • Family history of breast and ovarian cancers, especially first-degree relatives, on either your moms or dads side.

  • Personal history of multiple biopsies.

  • The age when you had your first child. If you were older than 30, your risk is higher.

  • The age you started menstruating. Your risk increases if you got your period before age 12.

  • Being on hormone replacement therapy.

  • Alcohol use. Some studies show that even one drink a day ups your risk.

  • High-fat diet. Generally speaking, there is a lower incidence of breast cancer in countries where people consume a lower-fat diet. And being overweight, often a consequence of a high-fat diet,
    is a breast cancer risk factor. For more details on what raises your breast cancer risks, visit Health.com/risk-factors.



5: Ive heard that mammograms dont catch certain cancers. Why?

Mammography isnt perfect, says Constance Lehman, MD, PhD, head of breast imaging at the University of Washington and Seattle Cancer Care Alliance in Seattle. Then again, nothing is perfect, and theres no doubt that mammograms save lives. The trouble is, these scans can find cancers in the form of a mass, calcification, or distortion, but they also detect benign forms of these abnormalities.

And if a cancer is very aggressive, theres a chance it could develop during the time between your mammograms and simply not be there to catch or not be big enough to see. Plus, there are cancers that dont produce malignant calcifications or dont develop as a mass, which are more likely to be missed by mammograms.

That said, one Harvard study projected that women who dont get screened would have a 56 percent mortality rate if they developed breast cancer, while just 5 percent of those who do get screened would die if they got cancer. Researchers are working on other ways to identify breast cancer early, including measuring circulating tumor markers in the blood. In the meantime, its clear that being screened routinely is a wise move.




6: Given mammographys limitations, what are high-risk women to do?

If youre at high risk, the new guidelines dont apply to you. High-risk women should start getting mammograms at 40 or younger while being closely monitored (often with an MRI and a mammogram alternating every six months and two clinical breast exams a year) and perform monthly self-exams. Some women opt for chemo-prevention drugs such as tamoxifen.

The most risk-reducing option—and also the most radical—is a prophylactic double mastectomy, which decreases your lifetime odds by at least 90 percent. “Its often peace of mind that drives your decision when youre at high risk,” Dr. Shapiro says.
 
7: Why are some doctors not following the new guidelines?

Even though there are limitations to mammography, says Otis Brawley, MD, chief medical officer of the American Cancer Society, which strongly disagrees with the new recommendations, its what we have for now.

“We think that if you inform people ahead of time of those limitations, its still appropriate to recommend [mammograms] to young women.” Whats more, he says, a higher proportion of women in their 40s with breast cancer have aggressive forms of the disease, and many of these women may benefit from regular screenings.

8: Arent these new guidelines really about money, since it reduces costs to screen women less often?

Dr. Brawley doesnt think the panels decisions came down to cost cutting. According to panel members, money was not a consideration. Rather, the task force focused on the inconvenience of mammograms and the fear, callbacks, and anxiety that they provoke.

Concerns about the risk of overtreatment weighed heavily, too. If you feel you need a mammogram and are in your 40s, Dr. Brawley advises, get one and fight for reimbursement if your insurer says it wont cover it.




9: Ive had scares in the past, none of which were cancer. Should I be doing anything differently?

Probably not, but talk to your doctor about whether you should be screened as frequently. Some women are simply more likely to develop abnormalities that can masquerade as breast cancer on a mammogram, says Therese Bevers, MD, a professor in the Department of Clinical Cancer Prevention at The University of Texas M.D. Anderson Cancer Center in Houston.

If youve had false alarms, remind yourself that more than 80 percent of callbacks are nothing to worry about. Try to think of them as a way to confirm that the finding is, once again, nothing. Another thing you can do: cut down on caffeine if it makes your breasts sensitive, or schedule your test just after your period. Why? “The less sensitive you are,” Dr. Bevers says, “the better compression well probably get,” which makes for a more revealing mammogram.

10: I just read that aspirin can lower my breast cancer risk. True?

The jury is out on this. “Some previous research shows that aspirin reduces breast cancer risk, but one trial tested a small dose of aspirin compared with a placebo and found no effect on risk. So either aspirin doesnt work or perhaps the dose was too low,” says Anne McTiernan, MD, PhD, of the Fred Hutchinson Cancer Research Center in Seattle.

Dont be confused by the results of the new aspirin study published in the Journal of Clinical Oncology. It suggests that the drug, when used by women who have already been diagnosed with breast cancer, cuts the risk of dying from the disease by up to 71 percent. But the findings do not apply to women who are cancer-free, Dr. McTiernan says. In short, do not take aspirin in hopes of preventing cancer; daily long-term use of the drug poses serious risks of stomach bleeding.




Got Implants? Heres What You Need to Know

On the one hand, if you have a lump, an implant often pushes the abnormality to the skin level, where its more easily detected by a clinical exam.

On the other hand, an implant can obscure parts of the breast that need to be studied in a mammogram, which means that mammography is less reliable for women with implants, says Helena Chang, MD, PhD, director of the Revlon/University of California, Los Angeles, Breast Center and professor of surgery at UCLA. One study found that the chance of a woman with implants getting a false negative on a mammogram was more than 40 percent.

Dr. Changs advice: “If you have implants and a palpable breast mass, dont rely only on a mammogram alone,” she says. Speak to your doctor about getting a targeted ultrasound and an MRI, or even a biopsy if those prove inconclusive.

And what if youre at high risk but you really want to get implants? Should you avoid them altogether? “Not necessarily,” says M.D. Andersons Therese Bevers, MD. “Implants themselves do not increase the risk of cancer.”

I Got to Keep My Nipples!

These days, I think often of the episode of Seinfeld, in which a character boasts about her breasts, “Theyre real, and theyre spectacular.” Well, right now, six weeks after I had a prophylactic mastectomy, mine are fake and, um, not spectacular—yet. Ah, but my nipples, at least, are real. My decision to have a mastectomy with reconstruction coincided with a development in the world of breast surgery thats gaining strength: some women, I learned, are candidates for keeping their nipples.

Before, says Nolan Karp, MD, director of the Breast Plastic Surgery Service at the New York University School of Medicine, the surgeon removed the nipple and re-created one later. “We could do a great job with flaps and make excellent breast mounds, but we could never make as perfect a nipple as the one you were born with,” Dr. Karp says. While I wont have the same feeling in my nipples as I did before, they look reassuringly the same, and I wont have to have another operation.

The procedure is new enough that there are no long-term studies on it, and I do think about the fact that keeping my nipples means I also keep trace amounts of tissue. But even though Im still recovering, I appreciate seeing those little nubs. Its like a piece of the old me is still there.

—Lambeth Hochwald

40 out of 45

Thats the number of breast cancer doctors and researchers Health asked who said they would ignore the new guidelines from the U.S. Preventive Services Task Force and start their routine mammograms at 40 and/or would advise a loved one or patient to do the same. (The task force recommended that average-risk women hold off on routine mammograms until theyre 50, and then get one every other year.)

According to an online poll of 454 women in their 40s conducted by Harris Interactive on behalf of LifeBridge Health, 67 percent also plan to continue getting annual mammograms, and some would even pay for mammos themselves, if need be.