Written by Dr. Elizabeth Williams-Drueding
Breast Cancer Screening: What You Need to Know
October is Breast Cancer Awareness Month, making it a good time to check in on breast cancer screening, risk, and family history.
While routine breast cancer screening primarily applies to women, breast cancer risk and family history are important for everyone to understand. Men can develop breast cancer, and inherited cancer risks can be passed down through either parent. Your father’s family history is just as important as your mother’s.
For women, an important question to ask is: Am I up to date on my breast cancer screening?
Breast cancer is one of the most common cancers in women. Screening helps find breast cancer before symptoms develop, when it may be easier to treat.
But screening isn’t exactly the same for everyone. Your age, family history, breast density, previous biopsies, genetic risk, and other factors can all affect what testing is right for you.
Here are the key things to know.
When Should Mammograms Start?
For women at average risk, mammography is the main screening test, and screening generally begins at age 40.
Major medical organizations vary somewhat on whether mammograms should be performed every year or every two years. Annual screening may detect some cancers earlier, while screening every other year may reduce callbacks and unnecessary testing.
The takeaway: If you’re 40 or older and haven’t had a mammogram recently, talk with your doctor about the screening schedule that’s right for you.
Screening often continues beyond age 74 when a woman remains in good health. Rather than relying on a specific age cutoff, you and your doctor can decide when the potential benefits of continued screening no longer outweigh the downsides.
What Kind of Screening Do I Need?
Mammogram
For most women, the mammogram is the foundation of breast cancer screening. Many centers now use 3D mammography (tomosynthesis), which can improve cancer detection and reduce some unnecessary callbacks.
Breast awareness
You don’t need to perform a formal monthly self-exam, but it is helpful to know what is normal for your breasts.
Contact your healthcare provider if you notice a new lump, nipple discharge, nipple or skin changes, dimpling, or another persistent change that is new for you.
And remember: a new breast concern should be evaluated even if your most recent mammogram was normal.
Do I Need More Than a Mammogram?
Some women benefit from additional screening, most commonly with a breast MRI.
Your doctor may recommend additional screening if you:
- Have a BRCA1, BRCA2, or another genetic change associated with increased breast cancer risk
- Have a calculated lifetime breast cancer risk of about 20% or greater
- Had radiation to your chest at a young age
- Have had certain high-risk breast biopsy results
- Have a strong family history of breast or related cancers
- Have dense breasts along with other risk factors
The best screening plan depends on your overall risk, not any one factor alone.
What Does It Mean to Have “Dense Breasts”?
If you’ve seen the words “dense breast tissue” on your mammogram report, you’re not alone. Dense breasts are common.
Breasts contain both fatty tissue and fibrous/glandular tissue. Having more fibrous and glandular tissue is described as having dense breasts.
Why does this matter?
First, dense tissue can make mammograms harder to read. Both dense tissue and breast cancers can appear white on a mammogram, potentially making some cancers more difficult to see.
Second, breast density itself is associated with an increased risk of developing breast cancer.
Having dense breasts does not mean you have cancer or that anything is wrong. It simply gives you and your doctor another piece of information to consider when evaluating your overall risk.
If you have dense breasts, continue getting your regular mammograms and talk with your doctor about whether any additional screening is appropriate for you.
If I Have Dense Breasts, Should I Have a Breast MRI?
Maybe. If you have dense breasts, it’s worth discussing with your doctor whether supplemental screening with a breast MRI is appropriate for you.
Dense breast tissue can make cancers more difficult to see on a mammogram. MRI is a more sensitive screening test and can identify some cancers that mammography may miss. However, having dense breasts does not automatically mean that everyone needs an MRI.
The decision depends on how dense your breasts are and your overall breast cancer risk.
Breast density is generally reported in four categories. The two categories considered “dense” are:
- Heterogeneously dense breasts: MRI may be considered depending on your other risk factors and personal preferences.
- Extremely dense breasts: Supplemental screening with breast MRI may be appropriate even when you don’t have other major breast cancer risk factors.
MRI is also generally recommended for women at high risk for breast cancer, including many women whose calculated lifetime risk is 20% or greater, regardless of breast density, more on this below.
Breast MRI has advantages and disadvantages. It can detect more cancers than mammography alone and does not use radiation, but it can also find abnormalities that turn out not to be cancer, leading to additional imaging or biopsies. A standard breast MRI also requires an IV contrast agent called gadolinium.
Importantly, MRI does not replace your mammogram. When supplemental MRI screening is appropriate, it is generally performed in addition to regular mammography.
The takeaway: If your mammogram says you have dense breasts, don’t panic, but don’t ignore the information either. Ask your doctor: “Given my breast density and my overall breast cancer risk, should I also have a breast MRI?”
Should Everyone With Dense Breasts Get an Ultrasound?
Not necessarily.
Adding ultrasound to mammography can find some cancers that weren’t visible on the mammogram, particularly in women with dense breasts. However, ultrasounds can find additional abnormalities that turn out not to be cancer, which can lead to additional imaging and biopsies.
For this reason, ultrasound isn’t generally used as a replacement for mammography or as a routine stand-alone screening test.
Ultrasound is extremely useful when evaluating a specific lump or abnormality. It can also be considered as supplemental screening in certain situations, particularly when MRI is recommended or desired but cannot be performed.
When deciding whether you need supplemental screening because of dense breasts, the conversation shouldn’t simply be “Do I need an ultrasound?” Instead, talk with your doctor about your overall breast cancer risk and which supplemental test, if any, is most appropriate for you.
Family History Matters — On BOTH Sides
This is important for both women and men.
Your father’s family history is just as important as your mother’s, because inherited cancer-related genetic changes can be passed down from either parent.
Make sure your doctor knows if relatives on either side of your family have had:
- Breast cancer at a young age, particularly age 50 or younger
- Breast cancer in both breasts
- Male breast cancer
- Ovarian cancer
- Pancreatic cancer
- Certain aggressive or metastatic prostate cancers
- A known BRCA1, BRCA2, or other inherited cancer-related gene mutation
Also mention if multiple family members have had breast cancer or related cancers.
Your ancestry can sometimes affect inherited cancer risk as well, so sharing your complete family background with your physician can be helpful.
Depending on your history, your doctor may recommend genetic counseling, genetic testing, earlier screening, or additional screening with MRI.
And this isn’t only important for women. A man with a significant family cancer history may also benefit from genetic risk assessment. Identifying an inherited cancer-related genetic change can provide important information about his own health as well as the health of his children and other relatives.
Can Men Get Breast Cancer?
Yes. Breast cancer in men is uncommon, but it does occur.
Routine screening mammograms are not recommended for most average-risk men. However, men should be aware of changes in their breast or chest area and talk with a doctor about any new or persistent changes, including:
- A lump or thickening in the breast or chest area
- Changes in the skin over the breast
- Nipple changes or a nipple that begins turning inward
- Nipple discharge
Certain factors can increase a man’s risk of breast cancer, including inherited genetic changes such as BRCA1 or BRCA2 and a strong family history of breast cancer.
Men with a known genetic mutation or significant family history should discuss their individual cancer risks and appropriate screening with their healthcare provider.
What Is the Tyrer-Cuzick Risk Calculator?
How does your doctor calculate a lifetime risk of breast cancer.
A breast cancer risk calculator is used.
The Tyrer-Cuzick model, also called the IBIS model, estimates a woman’s future breast cancer risk using information such as age, family history, reproductive history, breast density, and previous breast biopsies.
One important threshold is a calculated lifetime breast cancer risk of 20% or greater. Women who reach this level may be candidates for additional screening with breast MRI.
A risk calculator isn’t something you need to interpret on your own. It’s one tool your doctor can use alongside your complete medical and family history to develop an individualized screening plan.
Common Questions About Breast Cancer Screening
“I feel fine and don’t have any lumps. Do I really need a mammogram?”
Yes. That’s exactly what screening is designed for. Mammograms can identify breast cancers before they are large enough to feel.
“I got called back after my mammogram. Does that mean I have cancer?”
No. Callbacks are relatively common, and most do not result in a cancer diagnosis. A callback simply means the radiologist needs additional images or information to better evaluate an area.
“Should I worry about radiation from mammograms?”
Mammograms use a small amount of radiation. For women for whom screening is recommended, the benefits of detecting breast cancer generally outweigh the risk associated with this low-dose exposure.
“No one in my family has had breast cancer. Do I still need screening?”
Yes. A family history is only one risk factor. Many women who develop breast cancer do not have a family history of the disease.
“I have dense breasts. Should I get an MRI instead of a mammogram?”
Usually, no. Mammography remains an important part of screening. When MRI or another supplemental test is recommended, it is generally added to mammography rather than replacing it.
“I’m a man. Do I need a mammogram?”
Most men at average risk do not need routine screening mammograms. However, men should tell their doctor about any breast changes and make sure their physician knows about a significant family history of breast, ovarian, pancreatic, or prostate cancer. Men with certain inherited genetic mutations or other risk factors may need an individualized screening plan.
Your October To-Do
For women, take a few minutes this month to ask:
Am I due for my mammogram?
And consider asking:
Do I know my breast density?
Does my family history change my risk?
Would a formal breast cancer risk assessment be helpful for me?
Do I need genetic counseling or testing?
Is mammography alone appropriate for me, or should we consider additional screening?
For everyone, this is a good opportunity to learn more about your family cancer history.
Ask about cancer diagnoses on both sides of your family, including breast, ovarian, pancreatic, and prostate cancers. If possible, find out what type of cancer your relative had and how old they were when they were diagnosed.
That information can be valuable for your own healthcare and sometimes for the healthcare of your children and other family members.
Breast cancer screening isn’t completely one-size-fits-all. Understanding your personal and family risk allows you and your physician to develop a preventive care plan that makes sense for you.
At Active Health DPC, we’re happy to review your personal and family history, breast density, previous imaging, and other risk factors and help determine whether additional risk assessment, genetic counseling, or a different screening approach should be considered.
Medical Disclaimer: This article is for general educational and informational purposes only and is not a substitute for individualized medical advice, diagnosis, or treatment. Reading this content does not establish a physician patient relationship with Active Health DPC or its physicians. Always consult a qualified healthcare professional regarding your specific health needs. If you believe you are experiencing a medical emergency, call 911 or seek immediate medical care.
