Breast Exams and Mammograms: When Do You Need Them?

Most of my patients are justifiably confused when it comes to breast exams and mammograms — they’ve been getting mixed messages their entire lives. 

These days, most OB-GYNs adhere to recommendations from the American College of Obstetrics and Gynecology (ACOG). ACOG states that breast exams during an annual “may be offered in the context of a shared informed decision-making approach that recognizes the uncertainty of benefit.” Why are benefits uncertain? Because regular breast exams have not been shown to pick up breast cancer.

Yes, you read that correctly: Breast exams aren’t effective.

I am relieved that this is finally officially acknowledged. In the tens of thousands of breast exams that I have done, I have never detected a new cancer unless the patient came in with the chief complaint of a lump that she herself noticed. Even then, the vast majority of breast cancers have been detected on mammogram. When I do annual exams on my patients, I offer the breast exam but do not encourage it.  IMHO, the time is better spent talking about diet, exercise, and stress-reduction.

What does ACOG say about mammograms? They recommend that providers offer mammograms to patients starting between ages 40 and 49, definitely by age 50, and counsel about risks and benefits. Once you start mammograms, they should be repeated every 1-2 years, depending on risk factors and resources.

The American Cancer Society (ACS) differs in that they recommend annual mammograms beginning by age 45, and every 1-2 years after age 55. I don’t quite understand this last recommendation since breast cancer risk goes up steadily with age, so why offer to decrease frequency after age 55? But there you have it.

The US Preventative Task Force (USPTF) recommends that women ages 50 to 74 should get a mammogram every 2 years. For women in their 40s, the Task Force also found that mammography screening every 2 years can reduce deaths from breast cancer.

Finally, ACOG says to stop mammograms at age 75, and ACS states to stop these when life expectancy is less than ten years. This does make sense since the whole purpose of mammograms is to detect breast cancer before it is clinically noticeable. USPTF simply states, “For women age 75 and older, the evidence of the overall benefit of mammography screening is unclear.”

If your doctor has recommended a mammogram, you probably have some questions.

“Will it hurt?”

Yes, it can hurt to smoosh your boobs, but you’ll survive. It is less painful than having actual cancer that is detected too late. Though I do recommend scheduling after your period, when your breasts are less tender.

“Isn’t there a lot of radiation?”

No.

With the newer 3D mammograms, the average total dose for a typical mammogram is about 0.4 millisieverts, or mSv.

From the American Cancer Society: “To put the dose into perspective, people in the US are normally exposed to an average of about 3 mSv of radiation each year just from their natural surroundings. (This is called background radiation.) The dose of radiation used for a screening mammogram of both breasts is about the same amount of radiation a woman would get from her natural surroundings over about 7 weeks.”

“I heard I should get an ultrasound of my breasts if they are dense. Is that true?”

Yes and no.

Over 20 states have enacted legislation to notify women if they have dense breasts, and to offer further imaging. I think some of this is political, in that the jury is still out on the overall impact of this additional screening.

Having dense breasts is very common. It is a mild risk factor for developing breast cancer, and it also reduces the ability of a mammogram to find and accurately identify breast cancer. Breast density is determined by the radiologist: a woman has increased breast density when there is more breast and connective tissue than fat. 

I am not sure how I feel about adding this. I’ll let you know when I make up my mind.

“I’ve heard thermography is better than a mammogram.”

I do know how I feel about this one: The answer is no, it is not better or even equivalent.

Thermography detects subtle changes in breast temperature, which may be related to breast cancer. It was approved by the FDA as an adjunct to mammography in 1982. It is true that it is safe and radiation-free, but it is not a substitute for mammograms. This is where it gets dangerous.

There is a local business that offers thermography. Proudly displayed on their homepage:

Thermography is a safe adjunctive physiological procedure which may be useful in the diagnosis of selected neurological and musculosketal conditions ”

— American Medical Association

Useful in selected neurological and musculoskeletal conditions. Yup, nothing about the AMA endorsing it for breast cancer screening. (And why do they have a chiropractor interpreting the images?)

One last thing  . . .

There is no perfect screening and mammograms sometimes miss cancer. If you have a persistent lump or skin changes–especially any new nipple discharge or skin dimpling–ignore a normal mammogram and see your provider.

 

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