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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.