Are you confused about when to get your first mammogram, when to stop getting mammograms, and what type of mammogram is best?
The news media has lots to say about breast cancer, mammograms, and menopause. At times, I find myself a bit confused over all the conflicting opinions from doctors regarding the data. We all want to keep our breast friends healthy.
I was truly fortunate to be able to interview the AMAZING Dr. Daniel Kopans for his trusted advice. It would take me hours to do proper service in describing Dr. Kopans’ work on behalf of women’s breast health. He is a Professor of Radiology at Harvard Medical School and the Founder of the Breast Imaging Division at Massachusetts General Hospital. He is a leading international expert in breast cancer detection and diagnosis.
Dr. Kopans is the author of over 200 scientific articles. He invented the Kopans Wire, which is used in needle localization, making it possible for radiologists to accurately guide surgeons to lesions detected by mammography, making it possible to diagnose breast cancers at a smaller size and earlier stage excisional breast biopsies. He was also instrumental in creating the Breast Imaging Reporting and Data System (BI-RADS), the coding system used in all American mammography reports. He served as co-chair of a committee of the American College of Radiology that developed this system. This system helped to standardize the reporting of mammography results. Dr. Kopans invented and led the group that developed Digital Breast Tomosynthesis (DBT), sometimes called 3D Mammography, an advance in mammography that increases the detection of early breast cancers while reducing the need to recall women from screening for additional evaluation.
I have dense breasts and have been getting my mammograms on the tomosynthesis (often referred to as Tomo) since it became available. Thank you, Dr. Kopans, for inventing this machine. As I type this, I am virtually hugging this renowned expert. I am in awe and eternally grateful for his dedication, expertise, and the fact that he continues to speak truth to power and champion best practices for women’s breast imaging.
Breast imaging guidelines keep changing, resulting in women having reduced access to screening. It is challenging for a layperson to have clarity on the best practice in breast screening. I have a daughter aged 42 and a daughter-in-law aged 40. I was surprised that the guidelines now say it’s a woman’s choice to get a mammogram at age 40 rather than a standard and nationally recommended and accepted protocol.
Dr. Kopans explained, “There is always a choice about your own health care, but it is important to make informed decisions and of course, there needs to be access to the choices that you make. Unfortunately, there has been an effort for over a half-century to reduce access to screening. This is likely to try to reduce costs, but those involved know that if they tell women they do not want to spend the money to save their lives, they will lose the argument. Consequently, they have come up with scientific nonsense to try to delay access. All of these contrived concerns have been refuted by science.
The biggest false claim is using the age of 50 as a threshold for screening. There are no data by individual age (not grouped and averaged) that show that any of the parameters of screening, including lives saved, change suddenly at the age of 50. For example, I am fairly certain that if we looked at the ages at which the hairs on our heads turn grey it happens for some early in life, and others very late in life with a steady increase over the ages in between. However, if we look at the percent of us who are grey before the age of 50 and compared to the percentage 50 and over, it would look as if there was a sudden change at the age of 50 when this is simply an artifact of grouping and averaging with no sudden change. The same is true for breast cancer. If we look at 10,000 women at age 40, 10 will develop breast cancer during that year. At age 41 it goes up to 11; at age 42 it increases to 12 per year and so on until age 50 when it is 20/10,000 (I have used 10,000 so I don’t need to use decimals]. In fact, none of the parameters of screening change suddenly at the age of 50. There is no scientific basis for using the age of 50 (or age 45 as by the ACS) as a threshold for screening. Age 40 is the science-based threshold because the most scientifically rigorous studies called Randomized, Controlled Trials have proven that screening women ages 40-74 (the ages of the women who participated in the trials) saves the most lives. In fact, the groups that suggest delaying screening [The U.S. Preventive Services Task Force (USPSTF), American College of Physicians (ACP), and the American Cancer Society (ACS)] all agree that the most lives are saved by annual screening starting at the age of 40.”
Below in bold print, are the latest recommendations from Cancer.org. I asked Dr. Kopans to comment on each of them:
Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms (x-rays of the breast) if they wish to do so.
KOPANS: “This is the ACS recommendation which was a political compromise. If you read what they have written, you will see that they agree that the most lives are saved by annual screening starting at the age of 40.”
Women aged 45 to 54 should get mammograms every year.
KOPANS: “The more frequently you screen the better the chance that you will detect a breast cancer early enough to save a woman’s life. The ACP made this compromise for political reasons (starting at age 45 and changing to biennial at age 55) with no scientific support.”
Women 55 and older should switch to mammograms every two years or can continue yearly screening.
KOPANS: “More ACS compromise. There is no scientific support for switching from annual to biennial. The CISNET models, used by the USPSTF, ACP, and ACS predict that the most lives are saved by annual screening starting at the age of 40.
(Arleo EK, Hendrick RE, Helvie MA, Sickles EA. Comparison of recommendations for screening mammography using CISNET models. Cancer. 2017 Oct 1;123(19):3673-3680.)
Mortality reduction for various guidelines:
The American College of Radiology and the Society of Breast Imaging (the experts) agree and the CISNET models show that Annual screening for women ages 40-74 will result in 39.6% fewer deaths
The American Cancer Society compromised suggested Annual ages 45-54 and then biennial after age 54 and this would result in 30.8% fewer deaths
The USPSTF and ACP urge Biennial starting at the age of 50 which would result in only 23.2% fewer deaths
Estimating actual numbers for women who are now age 40
ACR SBI annual 40-74 saves 29,369 lives
ACS saves 22,829 lives
USPSTF saves 15,599” lives
Unfortunately, the groups that recommend delaying screening don’t tell you how many women will die whose lives could be saved by annual screening starting at the age of 40.”
Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer.
KOPANS: “This is simply reasonable since screening saves lives for a woman beginning 4-5 years after screening begins.”
All women should be familiar with known benefits, limitations, and potential harms linked to breast cancer screening.
KOPANS: “This is true for all medical interventions. Mammography is not perfect. It does not find all cancers and does not find all cancers early enough to result in a cure, but if breast cancer is not detected before a successful metastatic spread has occurred, it cannot be cured. We have gotten better at delaying death, but breast cancer is only cured when treated early. Until there is a universal cure, screening and early detection is the best way to save lives”.
I followed up with a few more questions that I have received from my subscribers:
Are all mammogram machines created equal? Should all women be getting the Tomo now?
KOPANS: “Digital Breast Tomosynthesis (DBT) is simply a better mammogram. It detects more cancers at a time when a cure is likely and reduces the chance that a woman will be called back for additional evaluation. I am biased because it is my invention, but numerous studies have shown that all women should be screened using DBT every year.”
How should a woman prepare for a breast scan?
KOPANS: “The only preparation is to not wear underarm antiperspirant because some of these can look like calcium deposits on the mammogram.”
I asked Dr. Kopans to comment on some of the options for women’s breast prevention:
Digital Mammograms- Digital breast tomosynthesis, also known as 3D mammography, is used for routine screening mammograms. Traditional 2D mammography is another option.
KOPANS: “DBT should be used for all screening since it includes traditional 2D mammography, and it detects more cancers at an early stage (more curable) and reduces the recall rate.”
Ultrasound – This uses sound waves to look more closely at masses, cysts, or duct abnormalities. An ultrasound can help diagnose whether you have a solid tumor or a fluid-filled cyst.
KOPANS: There are cancers that do not show up on 2D mammograms and even some that do not show up on DBT, that are visible on ultrasound. Screening with ultrasound, if done properly, takes additional time and, although I think it can add to the decrease in deaths that we have seen with mammography screening, there are no randomized, controlled trials to prove this.
MRI – If you are at a high risk of breast cancer, your doctor may want you to have a mammogram and an MRI. Together these tests can detect cancer early.
KOPANS: “MRI is actually the best way to detect breast cancer, but it requires the intravenous injection of a contrast agent; lying in a tube that some find claustrophobic; is very expensive; there are not enough MRI systems in the U.S. to screen all women.”
Molecular Breast Imaging – This is also called breast-specific gamma imaging. Nuclear medicine specialists perform it. They use a radioactive tracer and a special camera to see cancerous tissue in the breast.
KOPANS: “This is not a good way to screen since the radioactive agents injected intravenously, provide radiation dose to the entire body.”
Here in San Diego at UC San Diego Health, they now have contrast-enhanced spectral mammography (CESM). It uses a mammogram at two different X-ray energies and image subtraction to see areas of contrast enhancement in the breast. I spoke to Dr. William Ladd, a radiologist at UC San Diego Health who trained at Tufts University School of Medicine, then Harvard teaching hospitals for his internship and residency about this protocol. He explained that for the patient, it’s like a mammogram, except there is a contrast injection like a CT scan. It has a sensitivity almost as good as MRI, and better specificity, without having to go into an MRI machine. Works fine in extremely dense breasts, like MRI.
In addition, Dr. Ladd shared that UC San Diego Health has just purchased an estrogen receptor imaging with PET and a special radioactive tracer. It is specifically used for imaging estrogen-positive breast cancers. It is PET 3D imaging of the breast with a breast-sized circle. The patient doesn’t go into the machine. The imaging is performed one breast at a time.
If the above is inconclusive, your doctor may want to investigate more. You may need:
Biopsy – This is where they sample the breast tissue. The doctor will remove a small amount of tissue or fluid from the suspicious area and examine the cell under a microscope. A biopsy is the only way to directly tell whether cells are cancerous or benign.
KOPANS: “Most biopsies can be done using image guidance (mammography, ultrasound, or MRI) and can be done using a needle with local anesthesia. If the results are inconclusive or come back positive, then the radiologist can insert a guide into the suspicious area that the surgeon can use to surgically remove the area of concern using local anesthesia in an outpatient facility.”
Ductography – If you have an unexplained clear or bloody spontaneous nipple discharge, your doctor may recommend you have a ductography. They use contrast to help visualize what is going on inside the breast.
KOPANS: “There is not much value in using ductography.”
Localization – If you need surgery, radiologists can help precisely locate the lesion by marking the location of your tumor with a needle, wire, or tiny reflector. This helps ensure all cancerous tissue is removed and helps with cosmetic disfigurement.
KOPANS: “See Biopsy above”
Dr. Kopans leaves us with these critical words, “It is unethical for the USPSTF and ACP to tell women that they can wait until age 50 (with no scientific support for this as a threshold) and screen biennially without directly telling them what the estimates are as to how many will die, unnecessarily, by following these guidelines. They give percentage mortality reduction but don’t directly tell women how many deaths. There is little if any “overdiagnosis” of invasive cancers (of course, some women die before their cancer kills them, but, for the most part, this is unpredictable). The false arguments that have been promulgated over the past 50 years have all been shown to be scientifically unsupportable. It is also clear that the claims of massive “overdiagnosis” are not supported by the science.
The most lives are saved by annual screening starting at the age of 40.”
So, here is the bottom line: any reduction from annual screening starting at age 40 may save money and allows more premature deaths which cost money. The large clinical trials have established that if you begin annual screening at age 40, and continue that through age 74, your chance of dying from breast cancer is approximately cut in half. However, there appears to be no good data above age 74, but the consensus among the experts is to continue screening until the age estimated to be 10 years before death for each individual.
Unfortunately, we don’t have the same very large-scale strong data on any other regimen. The only rational argument for starting screening later, doing it less frequently, or having patients that don’t understand the science make their own decisions, is financial and it is not clear that doing this will save money.
I am approaching 69 and have no plans of dying in 10 years. I shall continue with my yearly breast screening!
Be a full partner at the table and get ahead of the curve on your breast cancer detection. Your breast imaging decisions can affect your quality of life and lifespan.
My Motto: Suffering in silence is OUT! Reaching out is IN!
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