Gilda Cardenosa, M.D., director of breast imaging at Virginia Commonwealth University Health, Massey Cancer Center, is the author of several preeminent textbooks on breast imaging. Cardenosa explains the recent changes to the ACS guidelines, why she views these changes as a mistake, and what they mean for women.
What changes did the American Cancer Society recently make to the breast screening guidelines?
Up until Oct. 20, 2015, the American Cancer Society’s recommendations were simple: screening mammography annually beginning at age 40.
Now the recommendations are more nuanced, and yet you can probably infer that annual screening mammography should be considered by all women over the age of 40. The ACS advocates, as do many physicians, that “women should have the opportunity to become informed about the benefits, limitations and potential harms associated with regular screening.” The recommendations ACS recently issued read as follows:
“Women aged 40-44 years: Women should have the opportunity to begin annual screening between the ages of 40 and 44 years. (Qualified recommendation)
Women aged 45-54 years: Women should undergo regular screening mammography beginning at age 45 years. (Strong recommendation)
Women aged 45-54 years should be screened annually. (Qualified recommendation)
Women aged ≥ 55 years: Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually. (Qualified recommendation)
Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer. (Qualified recommendation)
All women: Clinical breast examination is not recommended for breast cancer screening among average-risk women at any age. (Qualified recommendation)”
A qualified recommendation “indicates there is clear evidence of benefit of screening but less certainty about the balance of benefits and harms, or about patients’ values and preferences which could lead to different decisions.”
A “strong recommendation conveys the consensus that the benefits of adherence to that intervention outweigh the undesirable effects that may result from screening.”
I think the changes that the ACS issued are a mistake. There is a wealth of evidence supporting early detection, and I am concerned that the new recommendations are confusing to women and will reverse the progress made over the last decade in reducing breast cancer mortality due to early detection. For my full opinion on this issue, read my editorial recently published in the Richmond Times-Dispatch.
At what age and how often do you recommend that women at average risk of breast cancer should get screening mammograms?
I recommend screening mammograms every year beginning at age 40.
Screening mammography is not a perfect test, but it is one of the best screening tests we have in medicine. It enables us to diagnose the earliest forms of breast cancer so that treatment options are increased and the treatments are rendered more effective.
“Screening mammography is not a perfect test, but it is one of the best screening tests we have in medicine.”
How is average risk of breast cancer defined?
Average risk is a lifetime risk of breast cancer that is under 20 percent as calculated by risk models. In essence, most women are at average risk. Those at average risk have NO significant family history of breast cancer and do not have one of the gene mutations or genetic syndromes associated with breast cancer. Significant family history is having two or more first-degree relatives – mother, sister, daughter, father, brother or son – with breast cancer.
Who is at higher risk for breast cancer?
Any woman with a 20 percent or greater lifetime risk of breast cancer is considered at high risk. This includes women who are carriers of a breast cancer gene mutation (such as BRCA1 or BRCA2), women who have significant family history of breast cancer, and women who had chest wall radiation between the ages of 10 to 30 and who finished the treatment at least eight years ago. Various other factors can increase a woman’s risk for breast cancer.
Please note that many women who have had breast cancer do not fall into this high-risk group. In fact, only 5-10 percent of breast cancers are due to known genetic factors.
When and how often do you recommend that a woman should get screening mammograms if she’s at higher risk of breast cancer?
The frequency of mammography does not change for women in the high-risk group: Screening mammography is recommended every year. What may change is the age at which the screening is started as well as the addition of magnetic resonance imaging (MRI). In many women who are at increased risk, screening mammography is recommended starting at age 30 and breast MRI (magnetic resonance imaging) is added as an additional screening test.
What does breast self-examination mean?
This is something I encourage all of my patients to do and advocate that we encourage women in their late teens and twenties to do. This is an examination of the breasts done by the woman herself (or a significant other). To do an exam, start by inspecting your breasts in the mirror. Do you see any skin changes? Is there any redness or dimpling of the skin? Is one of your nipples changing? Do you see any changes in the contour of one of your breasts?
Then, while using soapy water, feel your breasts for any “lump.” If you find a lump, does it hurt? Does the lump change in size so that sometimes you cannot feel it? If you find a lump that does not change, please bring it to the attention of you health care provider. Although there are exceptions, many breast cancer “lumps” do not hurt.
Breast self-examination is best done one or two days after your menstrual cycle. If you have gone through menopause or do not menstruate, pick a day of the month to do the examination and be sure to do it regularly.
What changes in the breast should someone be concerned about?
Look for changes in the shape of one breast or if one is becoming thicker or harder (e.g., changes in the fit of one breast in your bra). Skin changes to look for include redness as well as puckering or dimpling. Nipple changes include retraction or inversion, redness or scaling of the nipple skin, an ulceration that will not heal or deviation of one of the nipples. Look for fluid that comes from the nipple without you squeezing or otherwise manipulating the nipple. Do not try to squeeze fluid out; but when doing laundry, check your bra cups for any small dark brown spots in the cup. Lastly, in checking for “lumps” – you are looking for something that feels hard and gritty, does not change over one or two months of checking and usually does not hurt.
Do you think that women should continue to get clinical breast exams?
Yes, I think women should continue to get clinical breast exams every year. I think this is important and not just about getting a breast examination. It is about getting a complete physical examination to include a blood pressure check, blood tests, including blood sugar checks, and pap smears at regular intervals.
Virginia Commonwealth University