Introduction: The Annual Mammogram
When you are a nurse of a “certain age”, it has been drilled into our brains that an annual mammogram is a necessity for basic cancer screening. We participate in Breast Cancer month, wear pink paraphernalia with pride. If we have friends requiring support, we attend annual walks and events to lend even more sustenance to mass education regarding a disease that will eventually claim up to 1 in 8 (13%) of us as we age. If we have not been personally affected, we know others that have, siblings, friends, aunts, parents, colleagues.
Personally, I have buried friends from this disease I could not bear to lose.
However, although we have been coached to believe an annual mammogram is necessary, is it really? After the recent death of Lucille Ball’s only granddaughter from Stage IV breast cancer at the age of 31, should we reexamine the premise of the annual mammogram, and pursue alternative ideas related to breast cancer protection? Perhaps the annual mammogram is not the only assistance we want or need in an arsenal to avoid breast cancer (as a disease that affects both females and males).3
Breast Cancer Statistics
As recently as 2019, an estimated 268,600 new cases of breast cancer were expected to be diagnosed in the United States, of which 2, 670 cases could be men. Additionally, an estimated 48,100 cases of DCI (ductal carcinoma in situ) will be expected to be diagnosed. “Approximately 41,760 women and 500 men were expected to die from breast cancer in 2019.” However, a much more encouraging statistic to know and understand is this: more than 3.8 million U.S. women were living with breast cancer as of January 1, 2019. This statistic included women who were cancer-free as well as those who still had evidence of the disease or were undergoing treatment.
More than 150,000 breast cancer survivors are living with metastatic disease, as a chronic condition.
Breast cancer typically has no symptoms, which is why breast self-exams are important. Most breast cancers begin in the milk glands (lobules) or the ducts that connect the lobules to the nipple. Symptoms that may occur could be a sense of “breast heaviness”, nipple discharge or retraction, swelling, thickening, or redness to the skin. Any or all of these should be immediate warning signs to seek medical attention and follow-up. Once a problem is detected, the next step would likely be a screening mammogram or tissue biopsy.
A mammogram is described as an Xray picture of the breast. It is portrayed in brochures as being a painless procedure (lol). Females may consider the mammogram to be slightly uncomfortable, or a bit distressing, depending upon the skill of the practitioner. If a woman has cystic breasts, or is premenstrual, flattening the breast tissue may cause actual pain, which may be alleviated by NSAIDS following the procedure.2
An initial mammogram is typically recommended between the ages of 40-49, for women with average risk, according to the following organizations:
- The American Cancer Society (ACS) recommends women ages 45-49 of average risk should begin mammograms every year.
- The American College of Obstetricians and Gynecologists (ACOG) and the American College of Radiology (ACR) also recommend annual mammography for women in this age grouping.
- The U.S. Preventive Services Task Force (USPSTF) and the American Academy of Family Physicians (AAFP) offer slightly different guidelines, stating women of average risk ages 40-49 may make their own decision regarding annual or biennial mammograms.
The bottom line: while professional groups differ on when and how often a woman should have her initial mammogram, the consensus opinion is that a woman of average risk should obtain a baseline mammogram at some point in her forties.6
Women with a BRCA mutation or a strong family history of breast cancer (a male or female parent or sibling with breast cancer) should start screenings earlier and discuss additional testing (e.g. ultrasound imaging) with their provider. Additionally, anyone who has a question about any abnormal or questionable finding in their breast tissue, nipple, underarm, etc. should seek medical attention ASAP no matter their age or medical history.
Between 2012-2016, the median age at the time of breast cancer diagnosis was 62, which means fully half of the women diagnosed were younger than 62 at the time of diagnosis. According to Mayo Clinic specialists, doctors continue to review guidelines regarding when and how often women should obtain mammograms in this age group. Why?
Mammogram screening is not perfect. Although more women are being diagnosed with early cancers due to mammograms, the number of women with advanced or late stage cancer has not decreased. The main concern with annual mammograms for all women is the risk of false positive findings, which then result in ultrasound exams, MRI follow-up, and/or biopsy to rule out malignancy. With mammograms, about 10% of women could get called back for further testing, but of that subgroup, only 0.5% will be found to have cancer.
At Mayo Clinic, physicians are encouraging women to be proactive and speak with their providers about the value of breast self-exams, understanding their risk for breast cancer via their personal history, as well as discussing the value of annual versus biennial mammograms for their personal health plan.
Most insurance plans are required to cover the cost of mammography for women between the ages of 40-64 with no out-of-pocket costs. The United States Preventive Services Task Force (USPSTF) recommends that women ages 50 to 74 years old receive a mammogram every two years, although many providers recognize the risk of death from CV disease begins to rise at age 70, making breast cancer screening less important.4
For individuals without financial means or decreased resources to obtain mammography, CDC offers a website with instructions for low-cost or free mammography @ CDC.gov., with assistance via state, territory, or tribe.
While we have long thought of breast cancer as one disease, it is not; it is a group of diseases that can affect both men and women. Additionally, it can become a chronic disorder with treatments spanning the full spectrum from diagnosis to invasive disease. While annual mammography has its benefits, an evolving healthcare landscape has acclaimed professionals suggesting biennial screening, self-exams, and lengthy, personalized conversation with a provider may be appropriate for many women. Ultimately, know your risk, understand what is best for you, and recognize when to seek medical attention.2
- Amp.cancer.org “American Cancer Society guidelines for the early detection of cancer.” (Breast cancer). Last revised July 30th, 2020, American cancer Society, 1-800-227-2345.
- Cdc.gov “What is breast cancer screening?” CDC-info, last reviewed September 14, 2020. U.S. Department of Health and Human Services, USA. Gov.
- Healthline.com “When should you get mammogram screenings?” Vermes, K., April 27, 2020. Healthline Media.
- Mayoclinic.org “Mammogram guidelines: what are they?” Pruthi, S. May 08, 2019, Mayo Clinic, Family Health Book, 5th Edition.