Screening Recommendations: The Bottom Line

When should I start getting a mammogram? What about breast ultrasounds? How often should I screen for breast cancer? Are breast self-exams enough? These questions are all relevant to women nearing middle age. We’ll answer these questions with screening recommendations, as well as make professional recommendations of our own. Let’s start with screening mammography.

When Should You Start Mammography Screenings?

The data is overwhelmingly clear. Women in the US should start getting their mammograms EVERY year starting at age 40. This is the formal recommendation of the imaging experts in the United States – the American College of Radiology (ACR) and the Society of Breast Imaging (SBI).

Numerous randomized controlled studies (RCTs) have shown that breast cancer mortality is decreased by approximately 40% with annual screening beginning at age 40. Yearly screening for breast cancer should continue if a woman remains healthy – and certainly past the age of 72 (which is the age at which most of the old, randomized studies stopped). At Harvard, 70% of breast cancer deaths occurred in the 20% of women who did not undergo breast cancer screening.

The United States Preventive Services Task Force has mistakenly recommended beginning imaging at age 50 and then only every other year. This is not based on science, but rather on biased opinion and, sadly, probably also on economics. A comprehensive restatement of the many flaws in the Task Force’s analysis is beyond the scope of this blog, but Dr. Daniel Kopans of Harvard has written extensively on this subject and the flawed methodologies employed by critics of routine screening mammography.

John Hopkins Medicine, along with the American College of Radiology (ACR) and the Society of Breast Imaging (SBI), recommends an annual mammogram starting at age 40: “A yearly mammogram for women 40 and older helps to detect breast cancer earlier, when it is most treatable, leading to less aggressive treatment and a higher rate of survival.”

It is our professional opinion, and the opinion of many other imaging experts, that women should undergo screening mammography on a digital mammographic imaging system with 3D tomography. This mammography option results in better image detail and fewer callbacks for potential abnormalities.

It is important to remember that sometimes cancer can occur between mammograms or be hidden on mammograms – particularly in women with dense breasts. Therefore, a lump should not be ignored if the most recent mammogram was normal. Interval cancers – those detected after a normal mammogram but before the next scheduled mammogram – do occur.

When Should You Use A Screening Breast Ultrasound?

An ultrasound usually is employed in problem-solving after a mammogram – to assess whether a nodule is cancer or benign – like a fibroadenoma or cyst. However, women with dense breast tissue should also consider undergoing a screening breast ultrasound, since mammography may not fully reveal cancerous nodes.

We highly recommend using screening ultrasound in women with dense breast tissue. Our radiologists have found small curative-stage cancers in women where they otherwise would not have been found. This procedure is covered by most insurance carriers; however, this procedure is important enough to even pay out of pocket if the procedure is recommended by your breast radiologist. Early detection saves lives.

When Should You Do Breast Self-Exams?

It is important to know your own breasts. While most cancers won’t be found this way, some cancers may be found due to discovering a new, worrisome lump. It is likewise incredibly useful to the imaging team when a woman can tell us that a lump we might be worried about has been there forever and is unchanged.

While we recognize that most organizations no longer recommend breast self-exams, tracking change over time is very important. The Mayo Clinic puts it as follows: “Most medical organizations don’t recommend routine breast self-exams as a part of breast cancer screening. That’s because breast self-exams haven’t been shown to be effective in detecting cancer or improving survival for women who have breast cancer. Still, doctors believe there is value in women being familiar with their own breasts, so they understand what’s normal and promptly report changes.”

While women should not rely solely on self-exams to find cancer, it is another tool in detection. Our organization recommends a breast self-exam every one to two months to track change over time.

When Should Screening Mammograms Start Earlier?

Women who are high risk should begin screening earlier – at age 30 – and include screening MRIs as part of their care regimen as well.

High-risk women include women with genetic mutations like BRCA 1 and BRCA 2. A BRCA mutation increases the lifetime breast cancer risk from a baseline of 12.5% to between 45 and 75%. Women with BRCA mutations should begin screening mammography at age 30, including yearly MRI exams of the breasts.

Our recommended procedure is to perform a screening mammogram, followed by an MRI 6 months later, followed by a mammogram 6 months later, and on down the line. After childbearing, a prophylactic (preventive) mastectomy can be considered for high-risk women.

Other high-risk women include patients with a strong family history, women with a prior breast biopsy showing atypical cells (ADH, ALH, LCIS), and women who have had chest radiation for a history of lymphoma (women in this category should begin screening at age 25 or 8 years after their radiation therapy – whichever is later).

The CDC defines a strong family history as someone who has:

  • One or more first- or second-degree relatives diagnosed with breast cancer before age 45
  • Triple negative breast cancer in a relative before age 60
  • A relative with breast cancer in both breasts at the same time
  • A relative who has had both breast and ovarian cancer
  • Any relative with ovarian cancer
  • A male relative who has had breast cancer
  • Two or more first- or second-degree relatives on the SAME SIDE of the family who have had breast cancer with one diagnosed before the age of 50
  • 3 or more relatives on the same side of the family with breast cancer at any age

A first-degree relative is a sister, or mother, or daughter. A second-degree relative is an aunt, grandmother, niece, or half-sister.

This can get a little complicated. We recommend using a breast cancer assessment tool, such as the one on our website, where you can assess your breast cancer risk. This is an easy way to figure out if you might need to start early, get MRIs every year, or even get genetic testing.

The Bottom Line

Regular exams are the best way to ensure life-saving, early detection. So when should you start? Based on your risk, we offer the following recommendations:

  • Most women should get yearly screening mammograms starting at age 40
  • High-risk women should get yearly screening mammograms and MRIs starting at age 30
  • All women should perform regular self-exams every month or every other month

Is it screening time for you? Call our office or visit our website to schedule your annual exam today!

 
 
Sources:
  1. “ACR Position Statement on Screening Mammography and Health Care Coverage.” American College of Radiology.
  2. Duffy, Stephen W., et al. “Mammography Screening Reduces Rates of Advanced and Fatal Breast Cancers: Results in 549,091 Women.” Cancer, vol. 126, no. 13, 2020, pp. 2971–2979.
  3. Webb, Matthew L., et al. “A Failure Analysis of Invasive Breast Cancer: Most Deaths from Disease Occur in Women Not Regularly Screened.” Cancer, vol. 120, no. 18, 2013, pp. 2839–2846.
  4. Kopans, Daniel. “Dr. Daniel Kopans: Topol Ignores Facts on Mammography.” AuntMinnie.com, 7 May 2015.
  5. Kopans, Daniel B. “Misinformation and Facts about Breast Cancer Screening.” Current Oncology, vol. 29, no. 8, 2022, pp. 5644–5654.
  6. “Mammograms and More: Breast Cancer Screening Guidelines.” Mammograms and More: Breast Cancer Screening Guidelines | Johns Hopkins Medicine, 19 Oct. 2021.
  7. “Breast Self-Exam for Breast Awareness.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 4 June 2022.
  8. “Breast and Ovarian Cancer and Family History Risk Categories.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 25 Mar. 2020.