Search for tag: "mammograms"

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.

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.

Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Interviewer: Can men get breast cancer? Turns out the answer is yes. Find out more about that next on The Scope.

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Ginger Johnson is the president of GetScreenedUtah.com. Mainly, you're an advocate for women getting screened for breast cancer, but I was surprised when you said that I actually could be at risk for breast cancer. How common is that?

Ginger: It's not very common, but it is possible. Men are a little bit different. Their lifetime risk of getting breast cancer is about 1 in 1,000. But the interesting thing is that a lot of guys aren't even aware that if they have a family member, a blood relative that has breast cancer that their chances of getting that actually increase. And so it's very important for guys to be aware that they have pecs. Those pec muscles can also have fatty tissue over them, that is breast tissue. And that tissue can be susceptible to disease, just like a woman's breast can be susceptible to disease.

Interviewer: So, as a man, if I tend to be a little bit heavier and have more fatty tissue, does that increase my risk?

Ginger: Fat is an interesting thing because fat tends to hold onto hormones. And so those hormones can actually trigger different kinds of cancer in your lifetime. That's why women are tested if they're estrogen or progesterone positive or negative when they get a diagnosis of breast cancer. But what we're finding is that guys aren't aware that if they have a lump on their chest, they just kind of blow it off. They won't go and say, "Hey, is this something that I need to look at?" Because they don't have the knowledge to even think, "Oh, this might be breast cancer," because it's such a foreign idea to them.

Interviewer: Yeah. It's fairly rare. Not a lot of guys are diagnosed with it, right?

Ginger: Not a lot of guys are. It's 100 times less common among men than among women. But, what we're seeing is that there are still about 2,000 new cases of invasive breast cancer that are going to be diagnosed this year.

Interviewer: So I'm sure you noticed that I started checking myself . . .

Ginger: You did.

Interviewer: Right?

Ginger: That's okay.

Interviewer: So is that what a guy should do? Is it, you're looking for a lump?

Ginger: Breast cancer can show up in a lot of different ways. There are actually 12 different ways that it can show up beside a lump. A lump, of course, is something that is very easy to see. You can feel it. But, it doesn't have to be a big lump. It can just be something small, like a pinhead, even, that's hard and immovable. If you think about breast tissue as, maybe, like a lemon. There's a great campaign on WorldWideBreastCancer.com that actually shows lemons. And, this is a great way for guys to really . . . that this can be, too. But, in their analogy of a lemon, you're looking for a bad seed. So it's going to be hard. It's going to be immovable.

It's going to be something that you go, "Oh, this, this isn't soft," like a bean, or something squishy, which could be fat tissue, or even a lymph node. This is actually hard and immovable.

Other symptoms, though, could be redness on the skin, itchiness that does not go away, hotness. If you feel like you're seeing erosion on the skin, or if your skin is starting to invert or look like an orange peel. There are a lot of different changes that can happen on skin. This is for men and women.

Interviewer: Okay.

Ginger: But, a lot of times guys don't get this education.

Interviewer: Yeah. Sure. I never would have thought that a rash could be something like male breast cancer.

Ginger: If it doesn't go away, it's always best, if it doesn't go away, if it stays consistent over the course of a couple of weeks, go in and get it checked. Just go so you can know and figure out what it is. Because, you definitely want to find it before you feel it.

Interviewer: So, are you recommending guys do self-exams? Are you recommending that they just be aware?

Ginger: I would say I would be aware. Because you are less at risk, I would just say, "Be aware of your tissue."

Interviewer: Okay.

Ginger: Be aware of your body. I would, honestly, talk to your doctor. I mean, guys don't often go into the doctor, we know how that is. But, if you're going to go in and talk to your doctor, and if you do have a family history of a mom, or a sister, an aunt, somebody in your family, just say, "Hey, Doc, what is this? Tell me what you know." Now, if the doctor you go to does not know, then you're going to want to do some research on your own because oftentimes doctors, themselves, we love them, they do as much as they can with the knowledge they have, but sometimes they might not have the knowledge for you. So you might need to get a second opinion.

Interviewer: Yeah. It might not necessarily even be on the radar . . .

Ginger: It's true.

Interviewer: Because it is, it does happen, but it is somewhat rare.

Ginger: It's true.

Interviewer: So, do guys then get mammograms, at that point? Just like a woman would?

Ginger: They would. They would have to go in . . .

Interviewer: Really?

Ginger: And have, have some kind of a mammogram, a ìMan-o-gramî if you will. But, they might do an ultrasound. There might be some other things that they're going to do for you. But there have been gentlemen that I know that have actually had mastectomies, where they've had to have that tissue removed. Now, it seems foreign to a guy to do that. But, they've actually had to go in and remove that breast tissue that is over the muscles so that they can remove any disease from that person.

Interviewer: All right. Any final . . . I don't know what else to ask at this point, other than, I'm going to start paying attention. And if I see something that's not going away, or feel any weird lumps, I'll talk to my doctor. And I'll know that if my doctor is, "What?" then I need to, perhaps educate myself. Anything beyond that?

Ginger: That's . . .

Interviewer: As a man?

Ginger: That's the best thing, and to realize, guys, how much influence you have in the women in your life. I don't think guys realize that the influence they have to say, "Hey, women, this is something that we all need to be concerned about. If I can get it, then obviously you can get it. Go in and get your mammogram." That's something they recommend for women, age 40 and over, to start with that baseline, and go regularly thereafter.

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Dr. Tom Miller: Screening to prevent breast cancer. We're going to talk about that next on Scope Radio. This is Dr.Tom Miller.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Tom Miller: I'm here with Dr. Nicole Winkler. She is an assistant professor in the department of radiology and also a specialist in breast imaging. How are you today, Nicole?

Dr. Nicole Winkler: Great, thank you for having me.

Dr. Tom Miller: There's been some interesting discussion in the press based on some research over the last few years that mammograms may not save as many lives as we thought. Do they save lives? Should women continue screening for breast cancer?

Dr. Nicole Winkler: Absolutely. That's a great question, because it's very controversial. Women are hearing different opinions from all directions, and it's hard to know what they should do. We recommend that screening mammograms are done every year starting at age 40. We do think that mammography saves lives. We have several randomized controlled trials that have shown a mortality reduction of about 30%. We think that may even be underestimated.

Dr. Tom Miller: You still think it's very important.

Dr. Nicole Winkler: Absolutely.

Dr. Tom Miller: Sometimes I'm confused by the literature myself. My patients will come in quoting something they saw on the Internet that maybe they don't need a mammogram as often, or maybe it doesn't help as much, and what should they do. I think that's very helpful. What about the interval? You mentioned beginning at age 40. There is some controversy about when to begin. Should it be 50, or 40, or even lower?

Dr. Nicole Winkler: There is. The U.S. Preventive Task Force Services recommends age 50, but we actually think...

Dr. Tom Miller: That's a conservative task force group I think, right?

Dr. Nicole Winkler: Yes, yes.

Dr. Tom Miller: There are several others, but I guess...

Dr. Nicole Winkler: There are several others. Many groups have challenged that recommendation. We follow the American College of Radiology and the American Cancer Society guidelines, and that's every year starting at age 40.

Dr. Tom Miller: Is it true that more lives are saved in women who begin screening at the age of 50 than between the ages of 40 to 50? That's been some of the things that I've heard.

Dr. Nicole Winkler: Yes.

Dr. Tom Miller: Maybe we screen between this 40 and 50 and it doesn't help as much.

Dr. Nicole Winkler: We still think that it helps. The mortality reduction is a little bit less than if you start at 50, but in women 40 to 50 they actually tend to have a little more faster growing cancers. That's why the annual mammogram is so important rather than bi-annual mammograms. We have studies that show that there is reduced mortality in that age range.

Dr. Tom Miller: What about 50 and over? Some of the women come in and say this is uncomfortable, I've heard you can do it every two years. Is that okay compared to every year? What's your thought on that?

Dr. Nicole Winkler: I think it's a good discussion to have of the pros and cons. The pros are if you have a cancer that's maybe very subtle, slow growing, we would be able to maybe pick that up sooner if you have it a year before than two years later. Also, with calcifications that's a sign of an early cancer, and if you let that go two years by the time you come in for your screening mammogram you may have a 2 centimeter cancer as opposed to a 1 centimeter cancer if you had come in every year. The goal of a screening mammogram is to find cancers early and to find them before they've gotten to the lymph nodes. Mammograms don't prevent breast cancer. They just find them early. If we do it every year we do think that that gives us more of a chance of finding a cancer.

Dr. Tom Miller: That's interesting. You mentioned that mammograms don't cause cancer, but I've even had patients come in and say they're reluctant to do a screening because they're worried about the radiation, because they've read that radiation from mammograms could cause cancer. What's your thought on that as a radiologist?

Dr. Nicole Winkler: I think it's an important question, because this is a medical device and it is a small dose of radiation to a patient. We think that it's a very low dose. I think having it annually doesn't affect your overall mortality as to whether you're going to get cancer, but there still are a lot of questions about that. We don't actually know from long term data what happens. We're still in that phase of mammograms are still pretty young. We've only been doing them for about 40 years.

Dr. Tom Miller: Also, the new X-ray machines, the digital machines, don't they use less radiation? Is that right?

Dr. Nicole Winkler: They do, yeah. We have regulations that we have to stay below a certain dose, and we're well below that dose here at Huntsman. That's probably the case at most American hospitals.

Dr. Tom Miller: That also brings up another question, because I'll have a patient come in and say because of the radiation I'd rather have an M.R.I. because I hear there's no radiation involved in an M.R.I. What's your thought on the different types of screening for breast cancer? Could we use an M.R.I. or other modality like ultrasound?

Dr. Nicole Winkler: There is no replacement for a screening mammography. Breast M.R.I. does not see the early calcifications that we would see on a mammogram. The other disadvantage of M.R.I. is that it's actually a pretty long exam. It's 45 minutes. They have to put an I.V. in and give contrast. It's an expensive test, and it has a high probability of us finding some things that are benign but that we have to work up.

Dr. Tom Miller: No procedures that don't show anything.

Dr. Nicole Winkler: Yes. We really only recommend breast M.R.I. in women that are high risk with a lifetime risk of over 20%.

Dr. Tom Miller: All right. For our older patients, older women, when is there a safe time to stop screening for breast cancer, or is there?

Dr. Nicole Winkler: There actually is not any really precise time that you should stop. The studies that were done on the benefit of screening mammography were for ages up to 74. No one really knows over age 74 whether mammograms help or not. What we usually recommend is that a woman who is 75, and in good health, and could live another 20 years probably should continue to have screening mammograms, whereas a 65 year old who has a lot of medical problems and maybe is not going to live for 10 more years probably should stop screening mammography. We usually say if your life expectancy is about five to seven years, and no one knows what their life expectancy is, then you could continue mammograms until you think probably not more than five years. The other thing I want to say about that, too, is women who get screening mammograms should be willing to continue on with whatever work up needs to be done.

Dr. Tom Miller: Breast tissue. Some of my patients will come in and say doctor, I don't have enough tissue to have a mammogram; do I really need a mammogram? A corollary to that is what about men and mammograms. Do they need to be screened for breast cancer? What's the thought on that?

Dr. Nicole Winkler: Men do not need to be screened. There is a little bit of controversy about men that have genetic mutations like BRCA mutations, but there is not really any screening recommendations for men.

Dr. Tom Miller: What's a BRCA?

Dr. Nicole Winkler: It's a breast cancer mutation.

Dr. Tom Miller: Gene, abnormal gene.

Dr. Nicole Winkler: Gene, an abnormal gene.

Dr. Tom Miller: That predisposes for breast cancer.

Dr. Nicole Winkler: Exactly.

Dr. Tom Miller: Right. Should all women have a mammogram, or can all women have a mammogram depending upon the tissue?

Dr. Nicole Winkler: Every woman can have a mammogram. If you've got skin we can squeeze it.

Dr. Tom Miller: The take home message for our audience is?

Dr. Nicole Winkler: The take home message is mammograms are recommended in all women age 40 and over annually. The time to stop is a little bit controversial, and you should have that discussion with your doctor probably around age 75.

Dr. Tom Miller: You heard it from Dr. Winkler. Thanks very much.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.

Recording: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life, you're listening to The Scope.

Interviewer: We're talking with Marjean Barnett, Director of Medical Imaging here at Teton Valley Hospital. Is there a lot of misunderstandings, do you think, with women as to how often they should get mammograms , when they should start? Do you feel that there's some confusion?

Marjean Barnett: I think there is, probably because the recommendations in the news change very frequently and there are national organizations that say, "Well, you don't need to start until you're 50 and you don't need to go more than every couple of years," but we sometimes will see a cancer appear that wasn't there just the year before.
I've seen a couple of cases of that just here recently. You really should get a baseline around 40 years old. Some of the more aggressive cancers occur in younger women, so if you're around 35 to 40 you need to be talking with your doctor about getting that baseline just to establish where you are.

Interviewer: So 40 is when women should really start worrying about it unless, I suppose, there's a family history of a particularly aggressive cancer then maybe earlier.

Marjean Barnett: That's correct, 40 is generally what's recommended. If you have family history like what's called a first degree relative would be a mother, a sister, a daughter, then you want to get your first mammogram earlier than the age at which they were diagnosed. Say if your mother was diagnosed at age 50 you definitely should have a baseline by the time you're 40, so ten years is a good window.

Interviewer: At 40 then how often after that?

Marjean Barnett: Usually yearly, our radiologist when they dictate the reports always recommend yearly.

Interviewer: Are there any disadvantages for a woman if she's like, "I really would like to start at 35," is there anything wrong with that?

Marjean Barnett: The only problem that might come up there is that younger women who are still producing a lot more of the female hormones estrogen and stuff, their breast tissue can be more dense which makes it more difficult to see clearly on a mammogram.

Interviewer: So it really doesn't make much sense because you're not going to be able to really see anything anyway.

Marjean Barnett: No.

Interviewer: Any final thoughts for our listeners? If there's one thing that they would take away and tell another woman what would you have that thing be?

Marjean Barnett: It's inconvenient at most. Some people think it's going to be horrible, but it's over quickly. It can save your life.

Recording: We're your daily dose of science, conversation and medicine. This is The Scope, University of Utah Health Sciences Radio.

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.

Announcer: Medical news and research from University of Utah Physicians and Specialists you can use for a happier, healthier life. You're listening to The Scope.

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.

Announcer: We're your daily dose of science, conversation, medicine. This is the Scope. University of Utah Health Sciences Radio.

What are the five threats to a woman's health? You might be surprised at what you learn. Today I'll tell you about the five for life, the five most important screenings and tests every woman needs to get and when you should get them.

For a lot of women, their priority is to take care of everyone else; your family, your work, your community, but you neglect taking care of yourself. That's why today I'm going to make it easier by telling you about the five for life. The five most important screenings you need. You should know how you stand on each one of these. Your cholesterol, your pap smear, your mammogram, your colonoscopy and you skin, testing and assessing all these for health is very important and you might be surprised at some of the things you hear.
Screening #1: Cholesterol

Women have always thought that heart disease was a man's disease. But after the age of 70, more women die from heart disease than men. Heart disease is the number one killer of women. And heart disease can be prevented if you control your cholesterol. So you should know what your cholesterol is, it should be tested by the time you're in your 40s and then every five years after that. Preventing high cholesterol or treating high cholesterol can save your heart. So even if you eat right and exercise and do all the things that you know you should do, most of what your cholesterol is doing and why it's doing it comes from your genes. You can do everything right and still have a high cholesterol.
Screening #2: Pap smear

It turns out that pap smears are very cheap, and although women don't like them, very easy to do and no one ever died from a pap smear. Even though you might think you might. Pap smears are, they are to detect cervical cancer. Cervical cancer isn't very common, only about 1 in 100, to 1 in 200 will get it. But it's treatable in its precancerous state and the screening test, a pap smear, picks up cancer before its cancer. So easy test and it's cheap, every woman should get one. Every woman should get one by the time you're 21, and then every couple years, but after you've had 3 normal pap smears you only need to get them every 3 years. Prevent it before it becomes cancer.
Screening #3: Mammogram

Women think that breast cancer is automatically a death sentence and that's not true. Breast cancer, if detected before it's advanced, is very curable and women who have their breast cancers detected by mammography only, no lumps yet, will have a 97% chance of surviving. So if you're going to detect it early you have to get your mammogram. There are controversies about when and how often but suffice it to say that at 50 you should have had a mammogram and then every year to two after that. High risk women, women who have a mom or a sister who've had breast cancer or who've had breast cancer before, should have their mammograms earlier and more often.
Screening #4: Colonoscopy

The Katie Couric test. Did you know that 1 out of 16 women are going to get colon cancer. Now that's actually more common than most people think it would be and colon cancer, like cervical cancer, has a precancerous stage that can be treated before it becomes cancer. So by 50, you should have the colonoscopy. Now it's another test that you don't want to do and it's a private test and it's yucky. However, it's not that bad, they give you some really fun juice to make you not be worried about it and it's much easier than your friends and family have told you.
Screening #5: Skin

Well, you look at your arms and you look at your face, but there are places on your skin that you can't see. And particularly in Utah, where people have been exposed to bright sunlight in the summer, we have more skin cancers as we age. So there are some skin cancers which are very deadly, those dark melanoma skin cancers which should be picked up early. So skin cancer is not a death sentence, in fact, skin cancers are the most common cancers in men and in women, and picked up early they can be removed with minimal surgery, but you have to pick them up, so somebody has to look at your skin and has to look at your skin all over. And that doesn't mean your honey. So your dermatologist should look at your skin.

The most important thing a woman can do about the five for life is, do them. Get a friend, do it together, grab your daughter, grab your mother, spend a day, do them and then go out to lunch, or go out to lunch, oh no, the colonoscopy, you have to get the lunch after the colonoscopy, not before. So get a friend and just make a day of it. Get all five done and then you're done, for at least maybe three years. Once every three years you should take care of yourself, and to do that, you can do the five for life in one half day through University of Utah Health Care, or talk to your doctor about what's appropriate screening for you when you go in for anyone of a number of issues. Say when should I be screened for these five things? The five for life. Your cholesterol, your pap smear, your mammogram, your colonoscopy and your skin screen. The five for life can save your life.

updated: February 7, 2020
originally published: September 25, 2013