For many American women, turning 40 means more than just an extra candle on your birthday cake.
When you reach this milestone date, you’re typically faced with a decision: to start regular screening for breast cancer or to push off commencing this routine wellness ritual.
The recommendation of when to start varies based on an assessment with your doctor of your personal risk and which agency’s guidelines you’re using. Dr. Janie M. Lee, professor of radiology at the University of Washington School of Medicine and director of breast imaging at the Seattle Cancer Care Alliance, explains that current guidelines for breast cancer screening are issued from multiple organizations including:
— The United States Preventive Services Task Force.
— The American Cancer Society.
— The National Comprehensive Cancer Network.
— The American College of Radiology.
— The Society of Breast Imaging.
— American Society of Breast Surgeons.
Recommendations vary by agency.
Dr. Kenneth Meng, radiologist at the Center for Cancer Prevention and Treatment at Providence St. Joseph Hospital in Orange County, California, explains that several of these organizations recommend beginning screening at age 40 for all women.
But not everyone wants to start that young. “The ACS guidelines for average-risk women allow for annual screening starting at age 40, but provide some alternatives for patients that may want to undergo less frequent screening,” he explains.
These ACS guidelines recommend:
— Women between the ages of 40 and 44 have the option to start screening with a mammogram every year.
— Women aged 45 to 54 are encouraged to get mammograms every year.
— Women aged 55 and older can switch to a mammogram every other year, or they can choose to continue yearly mammograms.
“Screening should continue as long as a woman is in good health and is expected to live at least 10 more years,” Meng says.
And despite variations from one guideline-issuing agency to the next, the fact remains that mammographic screenings have been shown to detect breast cancer at earlier stages when it’s more treatable.
More inclusive guidelines aim to detect breast cancer in vulnerable populations.
In June 2021, the ACR and SBI published updated guidance regarding mammography in the Journal of the American College of Radiology.
“These guidelines focus on women at average risk of breast cancer,” Lee says. “There are separate guidelines for women at high risk of breast cancer, such as women who carry genetic mutations that increase one’s risk of breast cancer, and women with a personal history of breast cancer.”
The revised guidance from ACR and SBI is “focused on being more inclusive of all women at average risk, and especially for groups of women that were not specifically discussed in detail in previous guidelines. For example, the updated guidelines highlight that Black, Asian or Pacific Islander and Hispanic women are more likely to be diagnosed with breast cancer before age 50 than non-Hispanic white women.”
As such, women in these demographic groups are being encouraged to begin annual mammographic screening at age 40.
“In addition, the updated guidelines highlight the LGBTQ community, who are less likely to present for breast cancer screening,” Lee notes. The guidelines specifically “recommend mammography screening for transgender women who’ve received hormone therapy for five or more years and transgender men who’ve not chosen prophylactic mastectomy,” a surgical procedure to remove breast tissue.
The hope is that with these changes, screening mammography will become more common among Black or transgender women who’ve been receiving breast cancer screening at lower rates than other groups.
As Meng notes, the incidence of breast cancer has been rising over the last few decades and is spiking among women under age 40, “which are out of the reach of any screening mammography recommendations.”
Meng also notes that the highest rates of incidence of breast cancer tend to occur nearly a decade earlier in people of Hispanic, Asian and African descent than in Caucasian individuals. “Given this shift in breast cancer incidence, for patients that value the lifesaving benefits of mammography, screening annually starting at age 40 saves the most lives and should continue to do so.”
Work with your doctor to select your optimal starting age for annual screening.
Dr. Kristi Funk, breast cancer surgeon, author of “Breasts: The Owner’s Manual” and co-founder of the Pink Lotus Breast Center in Beverly Hills, California, says she advises her patients who are at normal risk of developing breast cancer to “begin at age 40. Do it every single year, and don’t stop or don’t skip a year until you plan to die in the next five years.”
Dr. Elizabeth Arleo, a radiologist at New York-Presbyterian and Weill Cornell Medicine, agrees that starting at age 40 is generally best. “The reason for this is the greatest mortality reduction is achieved with annual screening starting at age 40 — a nearly 40% decrease in breast-cancer-specific mortality compared with only a 23% decrease in breast-cancer-specific mortality associated with the U.S. Preventive Services Task Force recommendation of biennially screening women 50 to 74.” The USPSTF is currently reviewing its guidelines.
What if I have a higher risk?
If you’re at higher than average risk for breast cancer because of a known genetic mutation or a family or personal history of breast cancer, you should begin screening earlier.
The American Cancer Society notes that most high-risk individuals will begin screening at age 30, but talk to your doctor about determining when you should start and how frequently you should be screened.
No matter how old you are when you start having mammographic screenings, there are a few things you should know before you head into that first exam.
1. Ask about the technology before you go.
Tomosynthesis, or 3D mammography, is becoming more commonplace, and Dr. Mitva Patel, a radiologist at The Ohio State University Wexner Medical Center in Columbus, says this technology results in fewer false positives, meaning you’ll have further testing or treatment for something that’s not cancer, than with conventional mammography.
“Sometimes when we look at 2D images, you have tissue superimposition, which makes something look like cancer but it’s just overlapping tissue. Most studies show there’s a 30% decrease in the recall rate for patients who have tomosynthesis, so I think it’s a good option,” she says.
When you book your appointment, ask whether tomosynthesis is an option.
2. Avoid scheduling too close to a COVID-19 vaccine.
The COVID-19 vaccines that are now widely available across the U.S. have worked wonders in preventing severe illness and death. But their impact on the immune system means its best to wait a few weeks after your last dose to schedule a screening mammogram.
To be sure, there’s no connection between COVID-19, vaccines against it and breast cancer. But for some women, the shot triggers temporary lymph node enlargement under the arm where the shot was delivered. This might appear to be abnormal on a mammogram image and trigger a callback for more imaging.
Your lymph nodes will return to their normal size within a few weeks of your shot. So for best results, the Centers for Disease Control and Prevention recommends scheduling your mammogram before your first dose of the COVID-19 vaccine or four to six weeks after the second dose to give your body time to return to baseline after making all those antibodies that can help protect you from COVID-19.
That said, if you have symptoms that may indicate breast cancer, don’t delay getting your diagnostic mammogram. Tell your doctor about your recent vaccine and follow their guidance on scheduling.
3. Don’t wear deodorant.
“Aluminum hydrochlorides in antiperspirants look like calcifications on your mammogram,” Funk says. These compounds commonly found in deodorants and some lotions and powders can show up on mammographic images as white spots, which can look a lot like tumors, so it’s better to be a tad stinky than wear deodorant to your mammogram.
This is “not true for ultrasound” screenings, Funk says, so it’s OK to wear deodorant if you’re having an ultrasound rather than a mammogram.
4. Expect at least four images to be taken — two of each breast.
When you arrive at the imaging center and are directed to the imaging room, you’ll be asked to disrobe from the waist up and put on a hospital gown.
Then, the technician will take four pictures — two images of each breast. “They will do an up and down (view), what we call the craniocaudal, head-to-toe position, where the beam is shooting straight down. And then they position you for an oblique, or mediolateral (view). Those four views will always be taken,” Patel says.
Arleo notes that taking two images of each breast is standard, but some women will have additional images made, usually for one of three reasons:
— “To make sure that as much of the far lateral (side near the armpit) aspect of the breast is included in the field of view.
— “If a patient has particularly large breasts (in order to image them entirely).
— “Or if the patient has implants (additional ‘implant displaced’ views are taken).”
For patients with implants, the technologist will “push the implant back and compress the tissue that’s in front of the implant,” so the implant doesn’t obscure a clear view of the breast tissue surrounding it, Patel explains.
Regardless of how many images are taken, Arleo says it’s important for women to relax during the procedure. “Work with the technologist to relax the body as much as possible to allow for the most all-inclusive images, even though it may feel for a few seconds like (you’re) a contortionist.”
5. Know the difference between diagnostic mammograms and standard screening mammograms.
Diagnostic mammograms, which is what you’d receive if a mass is detected on a screening mammogram or if you’ve felt a lump, can include several more views than the standard four views most women have during a screening mammogram.
Patel says visits for diagnostic mammograms take significantly longer than screening mammograms. “If it’s your first mammogram, but you’re feeling a lump, you’re going to be scheduled for what’s called a diagnostic mammogram.”
During a diagnostic mammogram, the technologist will “take the standard views, but then they’re going to show (the images) to the radiologist.” The radiologist will likely request additional images or an ultrasound. There might be several rounds of the technologist taking pictures and the radiologist reviewing the images and requesting more views.
From there, a decision will be made to do one of three things, Patel says:
— Doing nothing because the mass is nothing to worry about.
— Sending you home and asking you to return for more images in three to six months to see if something has changed.
— Ordering a biopsy to determine whether a mass showing up on film is cancerous.
“For diagnostic imaging mammograms, it’s a much longer exam, and I think that’s important for patients to know,” Patel says.
6. Know it’s just a few moments of discomfort for peace of mind.
“The pain is definitely worth the gain,” Funk says. “Studies have shown it’s actually painless for about 45% of people, and it’s a little painful for another 40%.” The remaining 15% report that mammograms are really painful. But among that 15%, Funk says 89% of them noted that although it was unpleasant, “the pain was gone in seconds to minutes.”
She likens it to stubbing a toe. “It hurts for a minute afterwards, but then you walk it off and you’re fine.”
A typical screening mammogram takes just a few seconds per image, and the whole process is usually over in about 15 minutes, of which you’ll be compressed in the machine for maybe a minute or two with breaks to catch your breath in between each image.
If you’re concerned about pain, Funk recommends scheduling the mammogram during days 14 to 21 of your menstrual cycle because this is when “you’re least sensitive.”
She also recommends taking an over-the-counter pain killer, such as acetaminophen or ibuprofen, about 30 minutes prior to the test to lessen pain and sensitivity.
7. Schedule it during the second half of your cycle.
Scheduling the mammogram during days 14 to 21 of your menstrual cycle offers an advantage not just for pain, Funk points out. This is also the time when your breasts are “least lumpy, which is important.”
Because of hormonal shifts in the body related to menstruation, “your breast density is slightly decreased during that week, which makes it less likely that you’ll be called back.”
8. Understand why they compress your breast tissue.
If you understand why they squish you, that might make it seem a little less awful. In short, flattening the tissue makes it easier to spot abnormalities.
“You want less overlapping tissue so you can see everything,” Patel says. Even with tomosynthesis, which takes a cross-sectional view, it’s still helpful if the patient’s breast tissue is flattened out because “it helps keep patients still. Motion can degrade an image.”
9. Know you can speak up.
If you’re in pain during the procedure, tell the technologist who’s taking the images, Patel says, as they may be able to reposition you in a more comfortable way.
“I’ve had patients say sometimes that their tummy is in the way or the machine is poking them,” and just communicating that to the technologist can help. “They have done so many mammograms, they’re able to work with the patients to get a good outcome,” she says.
10. Be patient for results.
You’ll get a letter in the mail and possibly an email or a phone call from the center where the mammogram was completed explaining your results. If you haven’t heard back from the center or your doctor within about a week, call to follow up.
11. Expect that you might get called back.
“Normally, when we look at mammograms, we compare to prior mammograms and we look for any changes,” Patel says. “Patients who’ve had multiple prior images — there’s less chance of us calling them back for additional views because we have more comparison films. For the baseline mammogram, (that’s your first one) unfortunately we don’t have anything to compare it to, so we’re more likely to find something that needs additional screening or images,” she explains.
This is also why it’s important to have all your mammograms conducted at the same center. If that’s not possible, be sure to keep copies of your films or have them forwarded on to each new facility you visit so the new radiologist has your entire imaging history for comparison.
Meng notes that while it’s true that any test you might need, “whether it’s going to get a mammogram, a blood draw or dentist (visit) to check for cavities, can be anxiety provoking, it’s important to know that the vast majority of times, being called back for a mammogram requires only a few additional pictures or an ultrasound to dismiss or clarify a potential finding and do not result in the need for a biopsy.”
In other words, try not to panic. The ACS reports that just two to four screening mammograms out of every 1,000 lead to a diagnosis of breast cancer, so even if you’re called back for more views, chances are good it’s not cancer.
12. It’s OK to be nervous.
Although screening for breast cancer is a routine medical procedure that’s performed thousands of times each day across the United States, it might be a really scary thing for you, and that’s OK. “Most women are always nervous about getting their annual mammogram,” Arleo says, whether it’s their first or 20th.
“It’s normal to feel nervous when going for a test whose purpose is to answer the question, ‘Might I have cancer?’ However, the important thing is to acknowledge the anxiety and then not let it prevent you from going to get a simple test which can be lifesaving,” she says. If you’re really scared, bring a friend or loved one with you and “remember that it’s worth it because annual screening starting at age 40 saves the most lives.”
13. Keep up with your screening schedule.
“Mammography saves lives and works best when women return for regular screening,” Lee says. “It would be nice if breast cancer screening was a one-and-done event,” but as with many other health choices, it works better “when chosen consistently over time.”
13 things to know before your first mammogram
1. Ask about the technology before you go.
2. Avoid scheduling too close to a COVID-19 vaccine.
3. Don’t wear deodorant.
4. Expect at least four images to be taken — two of each breast.
5. Know the difference between diagnostic mammograms and standard screening mammograms.
6. Know it’s just a few moments of discomfort for peace of mind.
7. Schedule it for the second half of your cycle.
8. Understand why they compress your breast tissue.
9. Know you can speak up.
10. Be patient for results.
11. Expect that you might get called back.
12. It’s OK to be nervous.
13. Keep up with your screening schedule.
More from U.S. News
Health Screenings You Need Now
13 Tips for a Mammogram originally appeared on usnews.com
Update 07/09/21: This story was published at an earlier date and has been updated with new information.
