The Breast Cancer Pre-Screening Test You Should Get by Age 30
There’s a standard piece of breast cancer screening advice you’ve probably heard a lot: Talk to a doctor about your breast cancer risk so you can decide together on the best screening plan for you.
It’s a suggestion that attempts to make some sense of confusing and often controversial mammogram guidelines by individualizing the regimen. Just as breast cancer treatment is becoming ever more specific, this is a step in the same direction for screening, Marc Hurlbert, chief mission officer of the Breast Cancer Research Foundation, tells Health. “I call it precision prevention.”
But the idea also leaves some questions unanswered. What doctor do you talk to? What kind of questions will she ask? When should this conversation happen, and afterward... then what?
An article published earlier this year in the Journal of the American College of Radiology addressing breast cancer screening recommendations for high-risk women has one idea: Let’s get all women evaluated for breast cancer risk by age 30. "All women, especially black women and those of Ashkenazi Jewish descent, should be evaluated for breast cancer risk no later than age 30, so that those at higher risk can be identified and can benefit from supplemental screening," the authors of the article wrote.
That urging, says lead author Debra Monticciolo, MD, professor of radiology at Texas A&M University Health Sciences and the section chief of breast imaging at the Scott & White Medical Center, stems from the fact that certain high-risk women could benefit from either earlier or different types of screening—or both. “We know supplemental screening is a benefit to women at higher risk, but if the women don’t know [they’re higher risk], they won’t have the screening,” Dr. Monticciolo tells Health. “If we start to do risk assessment to identify high-risk women, we can get them onto the right track.”
In an age where it feels impossible to find the time to make yet another doctor’s appointment, it might come as a bit of a relief that getting a breast cancer risk assessment doesn’t necessarily require a visit to a specialist with a months-long waitlist. A good place to start, experts say, is with your primary care physician or your ob-gyn. “I would say a woman should choose the provider they feel most comfortable starting the conversation with,” Dr. Monticciolo says. Your ob-gyn might have time at the end of your yearly exam, for example—or she might suggest you come back for another appointment where she can have a questionnaire ready for you.
Whichever doc you choose to speak with will likely ask extensive questions about your family history of not just breast cancer but ovarian and other forms of the disease. They’ll ask you about your personal history of breast biopsies, pregnancies, and hormone use, Dr. Monticciolo says. You'll also need to share details about your race and ethnicity, since some groups have a higher breast cancer risk than others, adds Hurlbert.
Someone deemed high risk after an assessment may be referred to a genetic counselor for more information or advised to undergo screening with MRIs or ultrasounds in addition to regular mammograms. “Once the assessment is made, the physician and the patient can talk about [needing] a higher level of genetics evaluation or supplemental screening,” Dr. Monticciolo says.
Not every PCP or ob-gyn will be well-versed in breast cancer risk, however, Dr. Monticciolo cautions. Yours may decide to refer you to a colleague or a breast clinic instead.
It's that lack of expertise among some doctors that concerns Charles L. Shapiro, MD, professor of medicine and director of translational breast cancer research and cancer survivorship at the Tisch Cancer Institute of the Icahn School of Medicine at Mount Sinai in New York City. “I think that the idea of the risk assessment at earlier ages is a good one,” he tells Health. “It’s an extension of people taking control of their own health and finding out what their risk is. But the practicality of it and logistics are not set up to do it at the current time. I’m not so sure the infrastructure’s in place.”
Primary care physicians and ob-gyns may not be trained in gathering an extensive family history or evaluating other risk factors, he says, and specialists may not have the bandwidth to see so many women.
But it may be worth the extra appointment or a lengthier wait if it means the results of your risk assessment are as accurate as possible. “You don’t want someone to think they are high risk or think they are not when they really are,” Dr. Monticciolo explains. Getting your level of risk wrong can result in unnecessary additional testing—or not enough.
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If you'd like to get at least a basic sense of your own breast cancer risk at home, there are online assessment tools that might be a smart starting point for now, Hurlbert says. He recommends the tools from the National Cancer Institute and AssessYourRisk.org.
Online tools have some limitations, of course, and you’re taking them at home without an expert nearby to help you interpret the results, Dr. Monticciolo warns. But an online tool can at least be a conversation starter. Print out or take a screenshot of your results, and discuss them with your ob-gyn or PCP, Hurlbert advises. It's part of being an empowered patient. “I believe knowledge is power,” he says.