by Jeffery Weigle, MD

In spring of 2019, the Food and Drug Administration (FDA) announced the first policy change in more than 20 years involving mammography services for women. The policies modernize breast cancer screening and provide patients with more information about their breast density, to aid in making healthcare decisions.

Breast cancer is the most common cancer in women regardless of race or ethnicity, according to the Centers for Disease Control and Prevention (CDC). Almost 85 percent of breast cancers develop in women with no family history of the disease (Reference Breastcancer.org). This makes screening for breast cancer, through monthly self-exams, annual doctor’s visits, and mammograms, an imperative.

To help women make better decisions about their risk and the kind of screening they need, the FDA has released a new policy on mammograms.

The FDA policy

The FDA recommendations are directed at mammogram providers but benefit patients.

  • Advising patients about their breast tissue density, a factor that can only be determined by a mammogram, and, in some women, changes throughout life
  • Advising that having dense breasts indicates a higher risk for cancer
  • Advising those with dense breasts to consider additional testing, such as an MRI or ultrasound, which are not affected by breast density
  • Officially adding new categories for mammogram assessment, including one called “known biopsy proven malignancy,” which would help healthcare providers identify cases where cancer has already been identified
  • Providing patients and healthcare providers with detailed information about the mammography facility

Note: Breast density notification has been a law in Virginia since 2012, one of 34 states already mandated to provide this information.

Breast Density

Women’s breast anatomy includes lobules (the glands that produce milk), ducts (that carry milk) connective tissue and fat. Each woman’s breasts are unique, with different amounts of connective and fatty tissues. Breasts with a higher proportion of connective or fibroglandular tissue compared to fatty tissue are considered dense. Denser breasts make it more difficult to spot tumors during a mammogram. Denser breast tissue also carries a higher risk for developing breast cancer than a family history of breast cancer.

Breast composition is a factor of genetics, age, whether or not you’ve had children, hormone replacement therapy, and weight. Breast density can only be determined by a mammogram, not by breast size or feeling.  

Screening for Breast Cancer

Mammograms are the best primary tool for breast cancer screening. They use an x-ray of breast tissue to look for abnormalities. Even before the FDA announcement, advanced mammography using cross-sectional, 3D, images of the breast taken from different angles, had been helpful in evaluating dense breast tissue. 3D mammograms are now preferred for all patients, and particularly for those with dense breast tissue.

Additional potential screenings use ultrasound or Magnetic Resonance Imaging (MRI) imaging.

Risk factors for breast cancer

The biggest factors that affect the risk of breast cancer are impossible to change.

  • Being a woman
  • Increasing age
  • Starting your period before age 12
  • Starting menopause after age 55
  • Having a mother, sister, daughter, or multiple family members on either side of the family who had breast cancer
  • Having radiation therapy to the chest or breasts before age 30
  • Having dense breast tissue

There are also a handful of risk factors that you can change:

  • Maintaining an ideal weight and losing weight if you’re obese
  • Not smoking
  • Getting sufficient exercise.
  • Taking hormone replacement therapy for menopause taken for more than five years
  • Taking some birth control pills

What to expect during a mammogram

An annual physical is a good time to discuss whether you need a mammogram. Your healthcare provider may ask about your family history and consider your age to determine when and how often you should schedule a mammogram. The Society for Breast Imaging and American College of Radiology recommend that annual screening begins at age 40, and sooner in some circumstances.

Before a mammogram you may be instructed to skip lotions and deodorant or asked to wipe them off your skin and underarm areas, as these products can impact the image. You will need to take off your shirt and bra. A technologist will position your breast on a small platform on the mammogram machine. A clear plastic plate will press down on your breast while the mammogram image is being taken. This compression of the breast helps spread out breast tissue, allowing for a clearer look. The technologist will ask you to hold your breath for 4-5 seconds while the image is taken.

Results from mammograms are reviewed by a radiologist and a written report is sent to your health care provider. FDA regulations require that facilities also provide patients a summary (in easy-to-understand language) their results within 30 days, and that they make reasonable attempts to communicate the results as soon as possible if indications of potential cancer are found.

Recommendations

If you have had a mammogram in the past, ask your health care provider about the density of your breasts and whether you should consider additional screening. The new FDA policy encourages patients to discuss their individual situation and risks with a health care provider in order to make better informed decisions.

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