Search for tag: "mammogram"

So you just had your Pap smear or your mammogram and it wasn't that bad was it? Or your colonoscopy. Okay, it really was that bad, but you didn't remember it. Are you wondering when you can stop doing these tests?

I asked a woman I know, who is in the health and fitness business, when she thought she could stop doing her cancer screening, you know, Paps, mammos, colonoscopy. She said, "Never," with a smile. She never wanted to stop her cancer screening, "It isn't all that bad, and it makes me feel safe," she said. I replied that cancer screening decisions about when and how often is a cost, risk, benefit analysis, and there are some data to inform that decision. She said, "You go with your brain, I go with my heart."

Well, let's go with the brain for a little while, okay? Let's start with Pap smears. The recommendations about Pap smears have been changing as we know more about what mostly causes cervical cancer -- the HPV virus -- and how fast it grows, usually not too fast. Cervical cancer does not increase with age for a lot of reasons. Sexual activity and the number of partners doesn't increase with age. Well, usually. And the cervix in postmenopausal women may not be as receptive to the virus. So there are good reasons to say that when you get to 65, if you've had normal Pap smears for the past 10 years, that means you actually have been having Pap smears in the past 10 years, and you haven't had an abnormal Pap in 20 years, you can stop testing. There's some pretty solid numbers to back this up, and the U.S. Preventive Services Task Force makes that recommendation.

Okay. How about colonoscopy? Well, colon cancer does not decrease with age. But if you don't have any family history of colon cancer and if your previous colonoscopies, that assumes that you've had some, have not shown any polyps or precancerous lesions, you can stop at 75. That's the recommendation of the U.S. Preventive Services Task Force and the American College of Physicians.

Lastly, mammography. Breast cancer does not decrease with age. It increases with age. The aggressiveness of breast cancer is less in older women than it is in younger women. But women still will get treated, which can be aggressive in and of itself. The U.S. Preventive Services Task Force said there's not enough evidence to recommend for or against mammograms at age 75 and older. But about a quarter of deaths from breast cancer each year are attributed to a diagnosis made in women after the age of 74. Women as they get older are less likely to get mammograms. About three-quarters of women 50 to 74 have had a mammogram in the past two years, but only 40% of women over 85. Of course, many women over 85 are in poor health, and mammography is just not on the list of things to do. And clinicians are less likely to recommend mammography if a woman is in poor health. The American Cancer Society suggests women should continue mammograms as long as their overall health is good and they have a life expectancy of at least 10 more years.

Well, how long am I going to live? I went online and Googled, "How long will I live?" There are lots of calculators because insurance companies and pension plans really want to know. Well, I tried a life expectancy calculator that was developed by the University of Pennsylvania and has been mentioned in the mainstream media. It asks sex not gender, age, height, weight, alcohol, smoking, diabetes, marriage status, whether I exercised, ate my veggies. I didn't fudge my weight or height. This calculator said I was going to live till 93 and I had a 75% chance of living to 85.

Another life expectancy calculator from confused.com asked me just a few questions, not my height or weight,or smoking, or alcohol, or diabetes. It did ask my relationship status, and options included happy relationship and married, but these were mutually exclusive. You could only pick one. Well, this one had my life expectancy of 97. And the calculator from Northwest Mutual, a well-respected life insurance company, cranked me out at 98.

Well, I really don't want to hang around the planet all that long. But I really hope that my savings will take me up there, and I'm going to have to have mammograms for a while yet.

Thanks for joining us for the "Seven Domains of Women's Health" on The Scope.

Dr. Jones: With respect to breast cancer risk, smaller breasts doesn't mean less. All breast sizes need mammograms. Women with different size breasts have ideas that breast size may affect the risk of breast cancer and the need for screening mammograms.

Well, breasts are different, and here to unravel some of the issues for us is Dr. Helen Mrose, a specialist in breast imaging and a radiologist here at the University of Utah. Welcome to The Scope studio, Dr. Mrose.

Dr. Mrose: Thank you for having me.

Dr. Jones: Okay, so when it comes to breast cancer risk, does size matter?

Dr. Mrose: Actually, no.

Dr. Jones: Okay.

Dr. Mrose: Size does not matter. People with small breasts and large breasts get breast cancer in equal frequencies or so we think.

Dr. Jones: Right.

Dr. Mrose: There are many things that matter having to do with breasts, including whether the breasts are dense or not, but that doesn't necessarily have a lot to do with breast size.

Dr. Jones: Oh, good.

Dr. Mrose: That's something we inherit.

Dr. Jones: Or we grow postmenopausal women, it turns out who gain weight after menopause, which happens. It's not uncommon for postmenopausal women, it's breasts that get larger, or for women who go on a diet and lose a lot of weight for their breasts to get smaller.

Dr. Mrose: Correct.

Dr. Jones: So there's some changes that go through in a woman's life.

Dr. Mrose: That's absolutely true. The breasts are composed of basically just two things -- fat and what's called fibroglandular tissue. And it's the fibroglandular tissue that is what's called dense. And for some reason, some people have very little fiber glandular tissue and some people have lots of it. And that has been found to be associated with breast cancer risk, but you're born with that or you develop when your breasts developed. You have a certain amount of that fibroglandular tissue, and you're absolutely right when the breasts get bigger, which they tend to do when people get older and they gain weight, they get more fat. But that's not known to be associated with breast cancer risk specifically.

Dr. Jones: So when it comes to early detection of breast cancer, does size matter in terms of how you do the mammogram or whether the mammogram is good at picking up cancers?

Dr. Mrose: Hopefully, not.

Dr. Jones: Oh, that's what I want to hear. Doesn't matter.

Dr. Mrose: Of course, when someone's breasts are very small, or if they're very large, it's more challenging for the technologist. We do have different size compression paddles to accommodate different sizes. And one thing that really matters is the skill of the technologist who's performing this study. And many people think it maybe it doesn't matter. It's just like snapping a chest X-ray. But doing a mammogram is quite an art that technologists who perform this are specially trained, they have to go through quite a bit different training than a regular X-ray technologist. And they have to keep up a certain number that they do and take exams. And they need to be supervised by people like me, who are the people who are watching the quality of their work and making sure that they're doing an adequate job. It's difficult to include all the breast tissue on the mammogram.

Dr. Jones: Well, here in the studio today, we have breasts of different sizes. And we won't use names, of course, because that would be HIPAA. But clearly, people with larger breasts to get all of the breast into it means you have to squeeze hard and squeeze all of it. So women who are large breasted tend to think that their mammograms hurt more, and people who are small breasted think that their mammograms hurt more. And I'd say hurt is all up to the person in this not up to the breast size. What do you think about that?

Dr. Mrose: That is true. It can be very painful or not painful at all. And a lot of it has to do with expectations, I think. A lot of it has to do with the skill of the person who's performing the examination. Because I think everyone having a mammogram feels some kind of stress because it's a test for cancer. It's one of the only tests that we do that's the only question is, is there cancer there? So of course, that's stressful.

But some people do not feel much discomfort. And it only lasts for a few seconds. The compression, which is what you're talking about that can be uncomfortable is really important for a number of reasons. The thinner we can get the breast tissue, the less radiation is necessary to produce the image. And this is really important, but also the thinner the tissue, the more detail we get by a lot, and the more things are spread apart, which is very important for our detecting things.

But when you ask a question about the size of the breast, when people have fatty breasts, which you can't tell by how they look or feel or even the size, they are easier to read, because we're looking for white things on the black background. Fat is black. When people have dense breasts, they have a lot of white background. And so we're looking for white things that might be hiding in amongst other white tissue. And therefore that compression is so important. We're spreading things apart so we can see those little white things.

Dr. Jones: Well, I tell women who, particularly women who've had labor, that it's nothing like a contraction. And if they can count to eight slowly, it's not going to last longer than eight seconds. Usually, by the time they really start cranking it down, and maybe we can all handle something, just a slow count to eight would get you through it.

Dr. Mrose: We can. And breast cancer is much more painful than having a mammogram.

Dr. Jones: Right.

Dr. Mrose: So I do encourage people, if we can find something early, or even in the pre-cancer stage, that that is a lot less painful.

Dr. Jones: That's a good way to put it.

Dr. Mrose: Yeah.

Dr. Jones: You know, we've heard a lot more about digital mammography and mammography, this and mammography that. I've told my patients it was always important to go to a center that had their radiologists on-site looking and supervising and did a lot of mammography. But are there any particular kinds of mammograms that are important?

Dr. Mrose: The most modern technology that we have is called 3D mammography or tomosynthesis. And this is a digital mammogram, but rather than just producing a 2D image, there are several slices, one-millimeter slices of tissue. So that we can page through the tissue like on a CAT scan or an MRI and see much, much more detail. It's actually incredible how much more detail we get with a 3D or tomosynthesis mammogram than with regular 2D.

Dr. Jones: So the patient isn't actually turning around in a 3D, you know . . .

Dr. Mrose: No.

Dr. Jones: . . . scanner. It's just the way that computer takes the image. That process of for the woman of having the image taken it's the same, but it's the way that computer takes the data.

Dr. Mrose: The machine is very similar, except the tube head where the X-ray is coming from actually moves. The woman doesn't move. She's just in compression, but the tube is making an arc so that it's taking images at different angles, just like in a CAT scan. That then can be synthesized with the computer to make the one-millimeter slices.

Dr. Jones: So do insurances pay for 3D mammograms?

Dr. Mrose: Absolutely, they do.

Dr. Jones: And is that what we normally do here at the U at the University of Utah?

Dr. Mrose: Most of our sites at the University of Utah are 3D. Certainly the Huntsman is all 3D.

Dr. Jones: That's great.

Dr. Mrose: Everyone is a specialist in reading mammograms, and that's something that is also important.

Dr. Jones: Well, so when do you recommend starting mammograms?

Dr. Mrose: I recommend for someone who's that average risk. What I mean by that is someone without a strong family history of breast cancer or known gene mutation that's associated with breast cancer. I recommend starting at age 40, and doing it yearly. And I know there's a lot of controversy about that. But the reality is all women are at risk for breast cancer. The majority of cancers that we find are on women without any known strong risk factor. And this means that having a discussion with your doctor about whether you should have a mammogram at 40, or how often is almost meaningless because everyone is at risk.

Dr. Jones: Think that's an important point because many women say, "Oh, I don't need to be screened because there's no breast cancer in my family." And I say only 5% of breast cancers are familial.

Dr. Mrose: Right.

Dr. Jones: The rest are still gene, you know, mutations, but only 5% of breast cancers are familial. And the rest is a DNA mutation that's made a cancer, but everybody needs to be screened. Well, so when do you recommend stopping screening?

Dr. Mrose: Well, since other than being female, which is the strongest risk factor for breast cancer, age is the strongest factor after that. When you hear the statistic that one in eight women will get breast cancer, that is actually not correct. It's one in eight women who reach 80 will get breast cancer, and that's very different. So what is important is if a woman is healthy, if she has a life expectancy of at least 5 to 10 years, I would say she should continue mammograms indefinitely.

And I have a 94-year-old mother who's healthy, plays pickleball every day. And I think she should have mammogram not because if she had cancer, we would do something aggressive. But I would have them take it out, which is a very straightforward procedure under local anesthetic, which would keep her from going on to develop something that would be very painful.

Dr. Jones: Well, I consider it a chance to go out, get out of the house and go out for lunch. So I think having a mammogram is a reason to meet with your friends and you know, have somebody take you or go with you and party a little.

Dr. Mrose: Many women do that. I had a group of friends from college who all came together in the . . . they called it the mammo van, and they would all come together and then we will all go out to lunch.

Dr. Jones: Well, although some recommendations about when to start and when to stop are still . . . you may hear different things. All women do need to be screened no matter what size they are. And Dr. Mrose, thanks for joining us with this and thanks for all of you listening on The Scope.

Interviewer: It can be a little confusing sometimes because there are actually two different types of mammograms. There's a diagnostic mammogram and then there's a screening mammogram. We're going to try to figure out the difference between the two of them so you can decide which one it is you might need.

Announcer: Health tips, medicals news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. Anna McGow is a radiologist at University of Utah Health. Let's break down the difference between the two different types of mammograms. First of all, what is a screening mammogram and who needs that?

Dr. McGow: Right, yeah. Thank you very much. So a screening mammogram, those are performed in women generally who are over the age of 40, 40 and above, who have no breast symptoms. So they do not have symptoms such as focal breast pain, they do not feel a lump, they have no breast skin changes, no nipple discharge, no skin retraction, no lumps in the armpits. Those particular types of symptoms would require a diagnostic mammogram and/or a breast ultrasound.

Interviewer: Okay. So just to be clear, you're going in for a screening mammogram if you have absolutely no symptoms of breast cancer, and that's the one that you just do every year, just so you can get a picture and see what's going on inside.

Dr. McGow: That's right, yeah, just to screen for breast cancer.

Interviewer: And if you have symptoms, then you're going to want to make sure that you're getting a diagnostic mammogram. What's the difference?

Dr. McGow: Yeah, no, that's a great question. So we have women who come in all the time just for a screening mammogram when in fact they should be getting a diagnostic mammogram. To get a diagnostic mammogram, again, a woman has breast symptoms that need to be evaluated and they need additional evaluation beyond the four standard pictures that we usually do for a screening mammogram.

The diagnostic mammogram and/or ultrasound requires a physician order, so from your regular family doctor or other physician. And when a woman comes in for the diagnostic evaluation, a radiologist physician, such as myself, needs to be present for that evaluation. As opposed to a screening mammogram, where a woman would just come in and get the standard four pictures and leave.

Interviewer: And that does not require a physician's order?

Dr. McGow: Those usually do not in Utah.

Interviewer: Yeah. That's just you go into your doctor and you'd say, "It's time for my regular screening mammogram."

Dr. McGow: Yes.

Interviewer: Got you. So it's important to know the difference. You say that there are times that a woman with symptoms will come in and will have been scheduled for a screening mammogram. How can they make sure that that doesn't happen?

Dr. McGow: So the first thing that they need to do is realize that they have a symptom and then call their regular physician's office and tell them about the symptom and request an order to be placed for a diagnostic mammogram.

Interviewer: Okay. So they might not even need to go in and visit with the doctor. They might have to.

Dr. McGow: Exactly. Usually, their physician will like to see them to evaluate the symptom, of course. But if not, if it's something urgent that the woman is very concerned about, they may go ahead and schedule that diagnostic mammogram evaluation with us first.

Interviewer: Okay. I can see how it can get a little bit confusing there at times.

Dr. McGow: Yes, yes. For sure. And so we just want to avoid women getting scheduled for screening mammograms when in fact they have symptoms and then being sent away if a radiologist physician is not there to evaluate them properly.

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Dr. Jones: You got your screening mammogram report and it said that you had dense breast tissue. What does that mean? Should you be worried? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care, and this is The Scope.

Announcer: Covering all aspects of women's' health. This is The 7 Domains of Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: First, a little about breasts. Breasts are mainly four kinds of tissue. There are the breast lobules, which is the part that makes the milk that is pretty quiet unless you're pregnant or breastfeeding. There are the breast ducts, which carry the milk to the nipple. There is the fibrous tissue around those other tissues that keep them from bumping into each other. And there is fat.

The difference between large breasts and small breasts is the amount of fat in the breast. In young, premenopausal women, hormones keep the lobules and the ducts pretty active and the ups and downs of the hormones can increase the fibrous tissue. Weight gain can increase the fat, and weight loss can decrease the fat in the breast.

Of course there's also skin on the top of the breast, and the nipples and their blood vessels, and lymph glands, but they don't really count in the mammogram business. With the traditional mammogram, x-rays go easily through fat tissue but don't go through fibrous tissue very well, and don't go through cancer very well. So fibrous tissue and ductal tissue looks white on a mammogram, and so does cancer. When a woman is young, under 50, or premenopausal, the breasts are more dense according to the mammogram. When you get older, the breasts become mostly fat and are easy to see through.

When a breast is easy to see through, it's easier to detect cancers. When the breast is dense, it's harder to see the little cancers. Now, dense breast tissue is common. About two-thirds of premenopausal women have dense breasts, and about a quarter of postmenopausal women. Put the two together, and about 40% of women have dense breasts. Postmenopausal women on hormone replacement therapy tend to have denser breasts.

When my patients were worried about the term dense breasts, I just told them that they had youthful breasts. Which is always nice to hear, but it made it harder for mammograms to see through the entire breast.

So what are you supposed to do? First of all, the letter you received about the results of your mammogram is often not understandable. In fact, a recent letter to the journal of the American Medical Association noted that letters about dense breasts were written on average at the 11th grade reading level. Of course our Scope Radio listeners, wouldn't have any problem with that. But many people read much more below that level.

On top of that, about 24 states have legislated the wording of dense breast notifications. Yup. That's what the legislation is called, dense breast notifications. And we know how well the government explains things for those of you who do your own taxes. So if your report says you have dense breasts, it doesn't mean that you have cancer. It probably also said that your mammogram was normal. Remember, if 40% of women have mammograms have dense breasts, then it's normal.

However, the wording is there and in many states it is legislated to be there so women can know that maybe their mammogram isn't as good a screening test as it could be. This is the time to talk to your clinician about your breast cancer risk and your worries, and there are several risk calculators out there on the web. Other Methods of Breast Cancer Screening

There are other methods of screening if you're at high risk. If there's a lump that you or your clinician noted, then an ultrasound might be useful. If you carry a breast cancer gene that puts you at risk, then an MRI might be recommended.

For all of us, though, the invention of digital mammography several years ago made mammograms much better at looking through dense breasts. So there's been less of a chance of missing something. And there are also some new techniques.

So if you got the letter saying that your breasts were dense, don't freak out. You are normal. If you're at high risk for breast cancer, talk with your doctor and maybe another imaging technique would be right for you. And you can check out the website areyoudense.org and that can explain a little, and you can celebrate the fact that you still have young breasts. At least on mammogram.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: January 10, 2019
originally published: May 19, 2016

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones, on The Scope.

Dr. Jones: Women get a lot of different information and they get a lot of different opinions about when they should start mammography. Some group of advocates which include OBGYN's and includes radiologists and includes the American Congress of OBGYN and the American College of Radiology says women should start having regular mammograms at 40. Mammograms at 40 vs. 50 Now the people who do science and actually look at how many women have to be screened for how long to save a life from breast cancer say that, in fact, we should probably start at 50 and that's what they do in Europe.

Now there are people who are in between that say, "Well, what you ought to do is just see what your breasts look like at 40, so get a baseline mammogram." So the concept of the baseline has never been adequately tested scientifically to see whether having that baseline and then not having another mammogram until you're 50 actually makes a difference. So in fact, I don't think it's a bad idea to get a baseline mammogram, but I don't have any evidence that it's going to save a life. And at 40, there are lots of things in an active, young breast - when I say that to 40-year-old women they don't, they say, "My breast isn't young." I say, "Oh, honey, you just wait till you get older. You still have a young, dense breast." So even that baseline mammogram, the nature of what makes a breast a breast at 40, when there are lots of hormones around makes it harder to see through and you end up getting called back. So even your baseline ends up causing a bunch of extra investigations and maybe some extra biopsies.

Having said all that, it ends up being a very individual choice because the science doesn't support routine mammography at 40 for everyone. The culture does. So the culture of regular mammography between 40 and 50 is such that, your girlfriends are getting mammograms and it's recommended by your doctor, so the culture in the United States is to get mammography. But the science actually doesn't support it, when you look at how many women have to be screened and how many lives are saved from screening compared to how many lives are disrupted with extra x-rays and extra biopsies and maybe even not very necessary chemotherapy. It's a tough call for women to know what to do.

Here's my take on it. I have women who come to me and say, "My girlfriend had breast cancer and I want a mammogram today." And my answer for that is you're 45. You haven't had a mammogram before. I think that's a reasonable thing to do. But remember breast cancer isn't catching and you can't catch it from your girlfriend, but if you don't feel safe right now and a mammogram will make you feel safer, then that's something that's okay. But remember mammography in the 40s, you find stuff that you have to investigate that isn't necessarily cancer.

I have women who come to me and say, "You know, my family we're down winders." Those are people who are exposed to nuclear radiation from the atomic bomb testing in Nevada and they are really anxious about radiation and they say, "You know what? I really don't think I want to do any extra radiation until it's really recommended." And for them I say, "You know what? I'm going to do your clinical breast exam even though there's no good evidence that doctors doing breast exams saves lives either, but if you feel better saving till 50, that's fine."

And then I have a few patients who say, "You know, my mom had mammography all the time and she still got breast cancer and died and I'm never getting a mammogram." That's a tough sell, because for them I think some screening is good in the 50s and 60s. On the other hand, I think it's going to be up to them and I don't want to make them feel like they're bad people because they choose not to have a mammogram, but every time I saw them I'd remind them and say, "What do you think about this year? How about a mammogram this year?"

So I think women are getting lots of different messages and I think it's a discussion. But I let women drive the agenda about how often they're going to have mammography within the parameters of either the advocates or the scientists.

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Dr. Kirtly Parker Jones: Should women have mammograms before the age of 50? This is Dr. Kirtly Jones from the Department of Obstetrics and Gynecology at University of Utah Health Care, and this is The Scope.

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Dr. Kirtly Parker Jones: It seems like in the last couple of years that there are new recommendations, or new debates, about when women should get mammograms. You may have heard in the news about a recent study that suggests that pushing mammograms back to 40 would save lives. Well, we are going to talk about this in The Scope today.
When Should You Start Getting Mammograms? What is the data? Where are we coming from? And where we're left. How do we make decisions about cancer? A study on women who died of breast cancer from 1990 to 1999, a while ago, found that 71% had not had a mammogram, and many of these women were under 50.
The authors recommend screening before 50. Now this argument has been evaluated by many organizations and many countries. The recommendation still stands for most national organizations to screen at 50. Disadvantages of Screening Too Early The difficulty in getting mammography before 50 is young women, premenopausal women's, breasts are dense. They have a lot more breast tissue in them and not so much fat, and it's hard for mammography to see through them. This being the case, it is harder to see the cancers that might be there.
Secondly, there are lots of things in women's breast that aren't cancer that can show up to be suspicious in young women's breasts. So many women will have biopsies; have surgical procedures, for areas which aren't cancer.
So how many women need to have a biopsy, a surgical procedure, for noncancerous area, to pick up one that really is cancerous? So the combination of young women's breast cancer being relatively rare and that breasts are hard to see through, and a lot more women are going to have biopsies and surgical procedures that don't need them, make us really want to consider what are the tradeoffs of early mammography before 50, in normal risk women, versus the regular recommendations?
Exceptions to the Screening-at-50 Rule And the tradeoff is there are going to be some women who will be getting breast cancers either because of their family history, their genes, or just bad luck before the age of screening. So these are uncommon, but very aggressive tumors that may start in the 20s, 30s and 40s. The difficulty for screening millions and millions of women is to come up with the recommendation that does the best good for the least harm.
So far, the trade off, the best good for the least harm looks like starting at 50. However, if you have a close family relative, a mom or a sister, who develop breast cancer before 50; if breast cancer "runs in your family", you should talk to your doctor about earlier screening mammography and maybe do genetic testing for genes that are associated with breast cancer. Breast cancer is frightening and it is literally close to our hearts. But we do best by doing the screening we should be doing. Get your mammogram at 50.
This is Dr. Kirtly Jones, and this is The Scope.

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