We’re so grateful to Carrie for taking the time to write this amazing article for us! You can read more about her here.
As an oncology clinical nurse specialist, I get fired up any time I hear about new breast cancer screening guidelines. Recently, my phone blew up on the release of those by the American Cancer Society. I wanted to take some time to let the hysteria settle and respond with what I see and know.
Breast Exams are Still Crucial
Every year women are diagnosed with breast cancer after CLEAN mammograms. Technologists mark the areas palpated in a clinical breast exam, prompting ultrasounds, and subsequent biopsies show cancer. Patients are doing their own breast exams, or providers are doing it for them. They feel something and are sent in for an evaluation—and guess what? Cancer on women with no family history, and often under age 40. How about the woman who comes for her screening mammograms every year, and well this year some early changes are seen and worked up, and cancer is diagnosed? The cancer is caught early.
In my practice, we celebrate breast cancer—sounds ridiculous, I know. But it’s the truth. Breast cancer is one of the only cancers we can find on surveillance, by women taking care of themselves . . . looking, searching for some evil cell changes. Breast cancer is curable, and often found on screening mammograms.
Breast Cancer is a Generic Term
These are the truths I know: The term “breast cancer” really bugs me. It’s not specific enough. Using that term is like saying that I own a car or that I like chocolate cake . . . so what? Breast cancer is a generic term for many types and subtypes of cancer of the breast. It is not all the same, just as all women are not the same. What bugs me even more is the “1 out of 8 women will be diagnosed with breast cancer” statistic thrown around EVERYWHERE. For the life of me I cannot understand why ductal carcinoma in-situ (DCIS) is NOT included in that number—even though it is considered a cancer (hold that debate for another time please) and accounts for 20-25% of breast cancers diagnosed. So the real number is about one in SIX women (1/6) will get breast cancer, just because we are women.
Self Exams Are Especially Important for Women Under 40
Nearly 13,000 cases of breast cancer in women under age 40 are diagnosed each year. Breast cancer is the most common cancer in women ages 15 to 39. Nearly 80 percent of young women diagnosed with breast cancer find their breast abnormality themselves. Thus, we should encourage self-breast exams! Young women are often diagnosed with more advanced breast cancer and/or more aggressive subtypes than older women. There are no effective breast cancer screening tools for women younger than 40 years old, so it is crucial that you are your own best health advocate. Breast cancer risk increases slightly for approximately 10 years after a first birth. After that, it drops below the risk of women who don’t have children.
Pregnancy, Breastfeeding and Mammograms
Oh, and while I have your attention, let’s talk about breast cancer and pregnancy. Breast cancer during pregnancy affects 1 in every 3000 women. Previously the issue of breast cancer in pregnant women was nearly non-existent as most were under age 40. Now we know more and more women are choosing to have children later in life, and the risk of breast cancer goes up as women get older. Most cancers LOVE estrogen, and pregnancy feeds estrogen in excess to the body. Because of this, it is anticipated there will be more cases of breast cancer during pregnancy in the future.
And breast cancer is the most common type of cancer found during pregnancy, while breastfeeding, or within the first year of delivery. Thankfully, mammography can be performed safely at any time during pregnancy.
Let’s use my scenario as an example. I was pregnant with my 3rd child at age 42. If I waited until after I delivered to have my mammogram, my mammogram would have become less sensitive to detect breast cancer because the breast tissue of a lactating women is very dense. If you wait until you’re done breastfeeding, as some suggest, that may up to two years or more—and that may be too long. On the other hand, if you are breastfeeding, you can still get a mammogram—just pump immediately prior to the mammogram. Yes, your mammogram may be a little less sensitive, but if in the hands of a breast radiologist specialist, they will still be able to read your mammogram and assess for changes.
Mammography is safe during pregnancy. A routine screening mammogram does not affect the unborn child. There is essentially no radiation exposure to the fetus during a routine screening mammogram. I would be more worried about radiation if I flew every week for work.
The Lack in Context of Detection and in Radiology Expertise is Disappointing
It is so sad that the authors of many of the articles I see cited lack individual patient data to make any statement about screening . . . still, they do it. There is no cancer registry in this world (unfortunately) that provides the information about the context in which the breast cancer was detected (e.g. whether the cancer was detected at screening, during the interval between screening mammograms, among non-attendees, etc).
I agree there are horrible radiology practices that miss diagnoses or have very high recall rates. But the KEY is to have standards for WHO is reading mammograms and benchmarking outcomes. Most studies look at ALL radiologists . . . and in the US they only need to read 480/year to be competent. On the other hand, in Europe radiologists read 5,000 mammograms a year. The evidence shows lack of expertise is a direct reflection on patient outcomes. MQSA (Mammography Quality Standards Act) Standards Reauthorization was due in 2007; it has yet to be done.
Part 2 of Carrie’s article series includes a summary of concerns with the new guidelines. It also includes recommendations from a world-renowned radiologist and breast cancer expert, and considerations from sources at the American College of Radiology and the American Cancer Society.
We’re so pleased to have Carrie on our advisory board! You can read more about her here.