Julia A. Smith, MD, PhD, is the director of the NYU Cancer Institute's breast cancer screening and prevention program and director of the Lynne Cohen breast cancer preventive care program at New York University in New York City.
Q: Do you recommend that all women perform breast self-exams and have clinical exams and mammograms?
A: Yes, I do. I recommend getting a baseline mammogram between the ages of 35 and 40 (to compare against tests later in life). Anyone over the age of 40 should have a mammogram every one to two years, and over the age of 50 yearly. Women should also see a doctor for a physical (or “clinical”) breast exam at least once a year. You should check your own breasts monthly. If you're premenopausal, check them as soon as your period ends.
Q: How important are breast self-exams?
A: Breast self-exams have never actually been shown in studies to decrease the number of women who die of breast cancer. However, I do advise women to check themselves because as they get familiar with their own breasts, they are more able to detect things that seem unusual.
Q: Do mammograms catch every cancerous tumor?
A: The main concern with mammograms is that they tend to produce false negatives, meaning that they will sometimes miss a lump. That happens in around 20% of mammograms. A mammogram will catch most cancers, though—and those are typically the cancers that would not have been caught by clinical breast exams or self-exams.
Q: Should more women get mammograms?
A: Yes, more women should. But unfortunately, the rate of women getting mammograms in recent years has been declining. Its not known why this is. It doesn't appear that doctors are recommending mammograms less, and it doesn't appear that women are not being properly referred. It seems that women are simply not showing up. Depending on the situation, these women are either skeptical, complacent, or scared.
Q: Should I be afraid of the radiation that mammograms produce by using X-rays? Could it give me cancer, maybe even breast cancer itself?
A: Studies have shown no increased risk of problems from mammograms, and the dose of radiation is lower than it used to be. The benefits far outweigh any risk.
Q: How do I know if I need a breast MRI?
A: Magnetic resonance imaging (MRI), which uses a magnetic field and radio waves to take pictures of the breast, is especially useful to get a closer look at patients who have a diagnosis of breast cancer. But MRIs are also often recommended for women who are at high risk for breast cancer, such as women with a family history of the disease, BRCA gene mutations, or previous personal experience with breast cancer.
Q: Are there any downsides to having a breast MRI?
A: While a mammogram can give a false negative, a breast MRI can result in a false positive. It's so sensitive that it can pick up things that turn out not to be cancer. If that leads to an unnecessary biopsy, it can be upsetting for the patient, not to mention the financial burden—or the fact that repeat biopsies may make future mammograms harder to read.
That being said, the breast MRI is a very valuable tool in both screening and diagnosis, and when applied correctly, the benefits of the procedure far outweigh the potential risks.
Q: How do I know if I need an ultrasound?
A: After a suspicious clinical exam or a mammogram, you may have an ultrasound, which uses sound waves to make a picture of the tissues inside the breast. The procedure can also be useful as part of standard annual screening for women with very dense breasts or at high risk for breast cancer.
Q: What should I do if there are no breast cancer screening facilities where I live?
A: Talk to a trusted family doctor or health professional and let them recommend someone. Keep in mind, however, that your mammogram needs to take place in a radiology setting and not in an oncologist's or general practitioner's office, because the reading of the mammogram and the upkeep of the mammogram machine have to conform to American College of Radiology standards. In very remote areas, the alternative may be a traveling mammogram van.
Q: How is mammography changing?
A: The technology has improved so that each mammogram X-ray delivers less radiation than before, further lowering the already low cancer risk. And theres been a standardization of the way mammograms are read and the way radiologists and technicians are certified. Another improvement is the advent of digital mammograms, which are not available everywhere yet, but they may be more accurate and easier to read for women who have very dense breasts or are very young.
Q: When are digital mammograms helpful?
A: If a doctor sees something suspicious on your regular mammogram, following up with a digital image may provide a clearer and more accurate look at the breast, in the same way a patient may benefit from an ultrasound or an MRI.
Q: What does the future of breast cancer screening look like?
A: We hope to be able to better identify each patients level of risk and then tailor screening procedures more to that level. This involves looking more closely at family history, using genetic testing, understanding ancestry and hormonal history, and factoring in personal breast history, such as whether there have been biopsies in the past and what they have shown.