Mammogram – When to start and when to stop

There are several recommendations floating around out there with controversy stirred most recently in 2009 by the United States Preventative Services Task Force (USPSTF), which recommended screening mammograms every other year for women above the age 50 with women 40-50 choosing when to start. The USPSTF also recommends against teaching women breast self-examination.

 

Before going any further, I will state that I disagree with those recommendations. An argument could be made for cost containment with many radiologist’s having a high call back rate for diagnostic mammography and performing a lot of biopsies. I assume the USPSTF feels decreased surveillance will lead to a decreased annual number of unwarranted diagnostic work ups and biopsies and consequently less health care dollars spent. This may be the case but decreasing surveillance is not the answer. Radiologists should be held to higher standards.

 

Now that I got that off my chest, screening mammograms are performed as a routine exam with the patient having no complaints. A diagnostic mammogram is performed if the patient was called back from a screening mammogram or if the patient presents with a complaint, such as pain, discharge, or a lump. Almost half of the diagnostic exams I see daily are for a patient’s presenting complaint, and of those, half are for a lump detected on self-breast exam.

 

It has been my experience that when women present with pain, we are not good at finding a source, at all! But if a patient presents with a lump, we are very good. We might find a cyst, a focus of prominent normal fibroglandular breast tissue, or possibly a mass (benign or malignant). In any case, we can with a degree of certainty state that we don’t see anything suspicious (normal breast tissue), see something but it’s not to worry (cyst, benign appearing mass), or we see something that gives us concern and should be biopsied (complex cystic and solid mass, atypical/irregular mass). Discharge falls somewhere in the middle, but more towards pain, without an identifiable source most of the time. Usually ultrasound is performed to look for a dilated duct with a mass representing a papilloma causing bloody nipple discharge. If a single duct can be expressed at will, then a small catheter can be used to insert into the duct and contrast injected. A mammogram is subsequently taken and a filling defect in the opacified duct represents the papilloma on ductogram.

 

So when do you start screening mammograms? The American College of Radiology and Society of Breast Imaging recommends starting at age 40 and I agree. If you have a first degree relative (mother or sister) with breast cancer, then you should start 5 years prior to their age at diagnosis. So, if your mother was diagnosed with breast cancer at age 34, then you should consider starting the screening process at age 29. But, if someone is under 30 years old the breast composition is usually quite dense making it more difficult to evaluate. Therefore, before the age of 30 an ultrasound would be considered the best screening modality and after age 30 mammogram could be performed.

 

As far as how often to get screening, every damn year!!! Don’t miss one year!!! I’ve seen several cases now of women skipping one to two year and coming back with a tumor that would likely had been detected during the missing years and had grown large enough for the patient to feel prompting their diagnostic mammogram.

 

So when do you stop getting mammograms? That I feel is a completely personal choice, but I would certainly stop when it is suspected that you might not live another five years, or possibly ten depending upon your personal state of health. I do agree with the concept that the cure might be worse than the disease.

 

That being said, my role as a radiologist is to detect and diagnose cancer. I identify cancers on mammography, ultrasound, and MRI. All should go on to biopsy, or why the heck did you get the exam to begin with. If the biopsy comes back negative, then return to routine ANNUAL screening mammography. But if it is positive for cancer, then consultation with a breast surgeon and oncologist is warranted to evaluate the road ahead and determine your own choices for your life. I hope that helped.

 

Let me know your thoughts in the comments section please!

 

Thanks,

Ron

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I am an American Board of Radiology certified Diagnostic Radiologist with a certificate of additional qualification in Neuroradiology. I absolutely love my job. I have learned a tremendous amount about the human body, including its’ expected complications given our extraordinary complexity, and get to use that knowledge to help people. I personally have experienced emotional devastation and loss, which has made me compassionate and empathetic. I really care about people, and I hope I can use this site to help you. I graduated medical school in 2004 from New York Medical College. My wife and I had our first son in NY where we bought our 900 sf two bedroom one bath starter home. I stayed at Westchester Medical Center for radiology residency, where we had our second son. I obtained a neuroradiology fellowship position at Yale New Haven Medical Center commuting about an hour and a half each way for a year while we had our third boy. Upon graduation I was fortunate to return to Westchester Medical Center to work in Neuroradiology, Body Imaging, and Women’s Imaging departments, a rarity in academic medicine. Almost a decade later and I am living in a larger home in Reno working in a private practice community based outpatient radiology group which contracts with a rural hospital in Elko, Nevada. My wife and I now have four boys and gave up on the girl. We also have a male Bernese mountain Dog named Helmut and female Newfoundland named Lucy. Despite all its hardships and tremendous struggles, I have an absolutely amazing life, which is a gift I cherish. It’s down to my philosophy. I am a firm believer in teamwork. So much comes down to communication. When healthcare providers talk to each other one-on-one, the patient care is always improved, every time! We might not find an answer to your problem, but our collective knowledge sure can help improve your chances. At Yale the best conference I ever regularly attended was a head and neck tumor board. The head and neck surgeon (otolaryngologist = ENT) presented the patient’s clinical history, the radiologist showed the images, the oncologist discussed the tumor and chemotherapy options, and the patient came to the conference and we all did a physical exam looking into their mouth to directly visualize a tumor. It was incredible! Patients came from far and wide to see this highly trained, world-renowned, humble, Japanese, gentleman surgeon. It was also an epiphany. I found that when I see the patient, talk to them, listen to their story, examine them and discuss the patient with my colleagues, the patient felt better and I had a lot of fun. It’s weird but reminds me of seeing a comedy where it is always funnier in a packed theater with everyone laughing. Knowledge and compassion are both infectious and contagious. My greatest days are helping patients deal with some of their most difficult days, and I am good at it.

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