When and how often are mammograms recommended?

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Mammography recommendations have been in the news recently, so I'm turning to Dr. Ravi Adhikary for an update on what we need to know about breast cancer screening. Dr. Adhikary is an assistant professor of radiology at Upstate, specializing in diagnostic radiology and breast imaging and intervention. Welcome back to "The Informed Patient," Dr. Adhikary.

[00:00:36] Ravi Adhikary, MD: Thank you very much.

[00:00:38] Host Amber Smith: Previously, women at average risk for breast cancer were told to start annual mammograms at age 50, but the U.S. Preventive Services Taskforce is now urging all women to get screened starting at age 40. What prompted this change?

[00:00:52] Ravi Adhikary, MD: The Task Force looked at more recent data and found that the incidence of breast cancer was increasing in this group -- in women who were in their 40s -- and when they looked at what they could gain by starting screening earlier, they did find that they would have an effect on mortality. So their new recommendation is to start at 40.

[00:01:18] Host Amber Smith: And why is this expected to be especially important for Black women?

When they looked at the data, the effects on mortality seemed to be especially high in Black women. It crossed over into all groups, but especially in black women. Do they think that that's because Black women were not getting mammograms early, or not getting mammograms routinely?

[00:01:43] Ravi Adhikary, MD: The reason why Black women have a higher mortality from breast cancer in general seems to be due to a number of factors, and one of them could be due to access. So this could help address the access issue by getting them in early and starting screening while they're young.

[00:02:03] Host Amber Smith: Now the task force advises every other year for mammograms, rather than annually, which, I think that's a change too. Does that apply to all women or is that just for those in their 40s?

[00:02:15] Ravi Adhikary, MD: The task force itself has always recommended screening every other year, for everybody from the age of 40 to until they're 75. Other organizations have slightly different recommendations. For instance, the American College of Radiology, they recommend starting at 40 and doing it every year, whereas something like the American Cancer Society, there is a little more nuance, where they say, from 40 to 45, you can discuss it with your doctor. From 45 to 55, do it every year. Then after that, do it every couple of years. Essentially what they're trying to do is kind of get the best aspects of mammography, while trying to minimize any risks that mammography may pose.

[00:03:09] Host Amber Smith: So with all of these different organizations having slightly different recommendations, what does a patient follow?

[00:03:19] Ravi Adhikary, MD: Part of that is individual, and one of the reasons why the task force indicates that patients should have it every other year is because they want to try to minimize what they think are the risks of mammography. And these risks include anxiety that a patient may feel from having to have additional testing. It may be that a patient has a biopsy that is negative, and they consider that a risk. Or they also consider another risk of overdiagnosis, where a cancer is found that may not affect the patient in their lifetime, which is very hard to kind of really quantify, but they consider that a risk. And so, their idea is we can minimize the risks but harness most of the power of mammography by having a patient come every other year.

[00:04:11] Host Amber Smith: I know women who had normal mammograms, and then 12 months later their next mammogram revealed cancer. And I hear you about the anxiety, but it might work the other way too. If women are afraid of this, maybe getting them annually would help reduce anxiety?

[00:04:30] Ravi Adhikary, MD: That is true. There are interval cancers that will develop if you do have screening every other year. And that is what some of the critics say about screening every other year, that on the flip side, if a patient has a cancer that has more time to develop and they have a larger cancer, the anxiety from having a larger cancer and having worse outcomes has to be considered as well, because the patient may not have as good a cosmetic outcome or need more treatment because the cancer has been given more time to grow. So that is one of the reasons why there are some guidelines that say, get screened every single year, to find the cancers as early as possible when they're as small as we can find them.

[00:05:19] Host Amber Smith: Well, let me ask you about what determines if someone is of average risk versus higher risk.

[00:05:26] Ravi Adhikary, MD: Sure. There are some models out there that examine this, and if a patient is concerned, they can actually talk to their physician or see a breast surgeon. And the models take into consideration different factors.

There are some risks that are softer risks and some that put a patient in an especially high risk category. And so some of the highest risk patients will have genetic mutations. The BRCA (tumor suppressor gene) mutation is one. There are others that also put a patient at higher risk for breast cancer.

Other risk factors include family history of breast cancer. There are patients who have had a biopsy with atypia (abnormality in cells in tissue) in the past and that can put a patient at higher risk. The time that a patient is exposed to hormones, which essentially means if they had an early menarche and had a late menopause, that is an additional risk factor, as well, that is somewhat softer than some of the other ones, but that's another risk factor. If a patient did not have a child, that is another risk factor. and there are others.

[00:06:36] Host Amber Smith: So, how does weight impact risk, and does breastfeeding history have a difference?

[00:06:44] Ravi Adhikary, MD: So weight... obesity is a risk factor, and it's thought to be a risk factor because fat itself can produce estrogen, and obesity may cause inflammation in the body. And so these factors may cause cancers to develop -- not only breast cancer, but other types of cancers -- to develop.

Breastfeeding is thought to be somewhat protective against breast cancer development. It's thought that when a patient is breastfeeding and they are not having regular menstrual cycles, this reduces their hormone exposure. And so they have a little bit of benefit from that. So that is potentially protective.

[00:07:28] Host Amber Smith: I know that breast cancer in men is really rare, but are there any screening guidelines that apply to men who may be at higher risk, who have a family history of breast cancer, say? Does that put them at higher risk?

[00:07:43] Ravi Adhikary, MD: It can. And the actual screening method would be an individual one, where the person would talk to their doctor. But if a patient does have a BRCA mutation, and they have family history, they may undergo mammographic screening, especially if they have gynecomastia, which is development of breast tissue in a male. But that is really pretty individual, and so they would want to talk to their doctor about what they can do.

[00:08:10] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, and I'm talking with Dr. Ravi Adhikary about new mammography recommendations.

Why does having dense breasts increase your risk for breast cancer?

[00:08:24] Ravi Adhikary, MD: The exact reason is not known, but some people think that it may just be due to the fact that you have more fibroglandular tissue, and the chances that there is a mutation that will lead to cancer is higher since you just have more tissue itself. The other thing about having dense breast tissue is that it makes a mammogram harder to read, potentially, where the tissue itself can mask a small cancer. And so we may not see a cancer as early as in a patient who has more fat within their breast.

[00:09:00] Host Amber Smith: How would a person know if their breasts are made up of dense tissue? Can you tell by feeling?

[00:09:07] Ravi Adhikary, MD: You cannot really tell by feeling. The best way is mammographically.

When we look at a mammogram, we see a mixture of fat and a mixture of fibroglandular tissue. And so we try to get an idea of the ratio. And we assign every patient who has a mammogram, a density. And that is actually, if it is in the heterogeneously dense or extremely dense level, we will actually send the patient a letter so they will know that they have dense breast tissue.

This is a state mandate and is soon to be a federal mandate. But a patient, if they do have a mammogram and they have dense breast tissue, they will know, by getting a letter.

[00:09:54] Host Amber Smith: Does the density of breast tissue change with age?

[00:09:58] Ravi Adhikary, MD: Generally, yes it will get less dense over time, and some patients will get dramatically less dense. Some don't change much at all, and it could be due to just evolution of normal tissue and replacement with fat.

[00:10:16] Host Amber Smith: Can you tell us about a recent study in the medical journal, JAMA Oncology? It focused on changing breast density.

[00:10:24] Ravi Adhikary, MD: Sure. What these researchers did was they looked at patients who eventually developed cancer and compared them to patients who did not. They looked at their mammograms and evaluated how the density of their breast change over time. What they found is that in the affected breast of a patient who developed cancer, the density did not change as much. It did not get as fatty over time. So that is, potentially, another tool that we could use. It's kind of a starting point. It's not something we could potentially use right away, but it may be at a point where we could do more research and figure out what we can do with this information. Can we use it to put those patients in a higher risk category and do additional screening? It's kind of a starting point, but it is an interesting observation.

[00:11:27] Host Amber Smith: So I know radiologists typically will compare a current mammogram with previous ones of a particular patient. Do they routinely compare the densities of both breasts?

[00:11:41] Ravi Adhikary, MD: What we do is we look at the density, and we can kind of see the density change over time, in most patients. What they did in this study was used computer analysis to get very fine detail on how the ratio of fibroglandular tissue to fat had changed over time and how it was different in each breast.

It's probably more detailed than we can just tell from simple analysis with our eyes. So it may be something where if we wanted to use this information, we may need additional tools to help us get that data. And then we could then take those patients that fit this characteristic and perhaps do additional screening with them.

[00:12:26] Host Amber Smith: Most of us have heard of a clinical breast exam where a doctor feels for any lumps or abnormalities. And we're familiar with the mammogram, x-ray of the breast. Can you talk about other methods of breast cancer screening and diagnosis, like ultrasound? I've heard that's used sometimes.

[00:12:43] Ravi Adhikary, MD: One thing about mammography that makes it unique is that it does have decades worth of trials and hundreds of thousands of women that have undergo undergone studies, and we have shown a mortality decrease. Other types of modalities don't have as much data, but they are useful.

So ultrasound, where we use sound waves to examine the breast, one nice thing is there is no ionizing radiation. And we can see through dense tissue with ultrasound better than with mammography. So it can be a supplemental tool in a patient who has dense breast tissue, and especially in a patient who has a higher risk than average and has dense breast tissue. Using ultrasound can be a good supplemental tool. It is also widely available, so that makes it a good surveillance tool as well.

[00:13:40] Host Amber Smith: When might a breast MRI be used?

[00:13:44] Ravi Adhikary, MD: MRI is a very sensitive modality. It is quite costly, and a patient has to get intravenous contrast, so it makes it less accessible. But it is utilized in the highest risk patients, for instance the patient with a BRCA mutation or other genetic mutation, or the patient who has a very strong family history, or who has had atypia on a prior diagnosis. Those patients may get additional screening with MRI. And using mammography and MRI in conjunction, will give us the most power to find a breast cancer early.

[00:14:30] Host Amber Smith: What is a PET scan, and do you use these for diagnosis?

[00:14:35] Ravi Adhikary, MD: So a PET scan, a patient is given a specific radioactive material called a radio tracer, and the radio tracer will go selectively to very active tissue, so it will go toward cancers. PET scans are not traditionally used to diagnose cancer. It is used when a patient has metastatic cancer, to look for deposits in other parts of the body.

The actual radio tracer will go toward a breast cancer, and so we can see it, but the field of view is just so much different. We don't get as much detail because the PET scan will actually scan the entire body and not just zoom in on the breast. But the radio tracer actually does go toward the breast cancer. It's just that we don't use PET scans to look for breast cancer.

[00:15:27] Host Amber Smith: For someone who has had breast cancer and survived breast cancer, do they go back to screening, or do the screening guidelines change for that person?

[00:15:39] Ravi Adhikary, MD: Some of that depends on the institution. Here, at Upstate, we generally will examine the affected side more closely for a couple of years. So we may do six month interval mammograms to see that there's no immediate recurrence. After that, they can have standard screening. They may want supplemental screening, especially if they had breast cancer diagnosed early. And the supplemental screening can be done with ultrasound or MRI.

[00:16:07] Host Amber Smith: We've talked about a lot here with mammograms. And I guess the overarching was that the preventive task force is recommending that they start earlier for women in their 40s. Does Upstate follow that, or does the institution have a guideline in place? Or what should patients ask their doctors about?

[00:16:27] Ravi Adhikary, MD: So at Upstate, we generally will recommend what the American College of Radiology recommends, which is starting at the age of 40, having a mammogram every year. If a patient is not comfortable with that, they can also talk to their doctor about modifying that. And if a patient has a strong family history or other sorts of high risk factors, they can talk to their doctor about starting early or using supplemental tools like ultrasound or MRI, potentially.

[00:16:57] Host Amber Smith: Dr. Adhikary, you've really helped us understand this. Thank you for explaining it so well. I appreciate you making time.

[00:17:04] Ravi Adhikary, MD: You're welcome. Thank you for having me on.

[00:17:06] Host Amber Smith: My guest has been Dr. Ravi Adhikary, an assistant professor of radiology at Upstate, specializing in diagnostic radiology and breast imaging and intervention. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.