Dr. Norton’s Mammography Blog

According to data from the 2004 Behavioral Risk Factor Surveillance System (BRFSS) only 58% of US women aged 40 and older had a mammogram within the last year.  The percent of women aged 40 and older who had a mammogram within two years increased from 29% in 1987 to 70% in 2000 and remained stable through 2003.  However, since that time mammography utilization has decreased.  In 2005, the screening rate was 4% lower than in 2000.  How can this be when we know from large international studies that annual mammography performed on women over 40 reduces breast cancer mortality up to 40%?

There are multiple reasons for this decreased utilization.  Socio-economic status affects screening rates.  Women with less than a high school education; those without health insurance; and immigrants are less likely to undergo regular mammography.  Access to services is also a problem.  The number of breast imaging facilities has not kept up with the growing U.S. population of women over 40.   Additionally, many breast imaging facilities have closed due to lack of personnel, financial constraints and malpractice concerns.  This has occurred in a face of a screening population that grew by 24 million between 1990 and 2000.  Finally, many women remain fearful of the mammogram examination itself with some complaining about discomfort and a few even believing that the exam itself can cause cancer.

The solutions to the problem of falling utilization will not be easy and will require not only increased education regarding the benefits of mammography, but also the need to provide more convenient access for all eligible women must be addressed.

Postmenopausal hormone replacement treatment (HRT) has been used for many years to help relieve postmenopausal symptoms and slow or prevent osteoporosis. However, in the last several years many studies have raised concerns about the association of HRT and the increased risk of developing breast cancer. Although the specifics of these studies show some variability, the consensus is as follows.

It is clear at this time that long-term use of combined hormone therapy (estrogen plus progesterone) increases the risk of breast cancer and may increase the chance of dying of breast cancer. The use of estrogen alone and its effect on breast cancer incidence is less clear, but some studies have found that long-term use of estrogen (more than 10 years) increases the risk of ovarian and breast cancer.

So what are the current recommendations?

Other than short-term relief of postmenopausal symptoms, there are few strong reasons for use of postmenopausal hormone treatment. If HRT is needed for relief of postmenopausal symptoms, each woman should work with her physician to find the lowest possible dose that works for her and for the shortest amount of time.

I recently interviewed Ruthie Bolton (formerly of the Sacramento Monarchs) who asked me if African American women had a higher risk of developing breast cancer.  This is an interesting and often
misunderstood topic.  First of all, irregardless of ethnicity all women over 40 should have annual screening mammography.  However, when one looks at breast cancer incidence as published by the American Cancer Society, some surprising data presents itself.  ACS surveillance review published in 2007 showed that breast cancer incidence was highest in Caucasian women (132 per 100,000), followed by African American women (118 per 100,000), Hispanic women (89.3 per 100,000), Asian American
women (89 per100,000) and finally American Indian women (69 per 100,000).

However, female death rates related to breast cancer in African American women (34 per 100,000) were highest amongst all ethnic groups followed by Caucasians (25 per 100,000).  Additionally, African American women are less likely than Caucasian women to survive 5 years:  77% versus 90% respectively.

The reasons for this lower survival are diverse. Aggressive tumor characteristics appear to be more common in African American women.  Additionally, presence of chronic illnesses, lower socio-economic status, and delayed access to medical care also contribute to this disparity.  Again, this scenario should reinforce that early detection is the single most important tool to identify and thus treat breast cancer at its earliest stage.  Access to services such as mammography should  not compromise a woman’s opportunity to receive this important service.

For many years, screening mammography has been the “gold standard” in detecting early breast cancer in all women regardless of underlying risk factors.   With the development of new breast imaging technologies, namely breast MRI, the screening strategy for women with especially high risk of developing breast cancer has changed.  MRI has been shown in numerous scientific studies to be the most sensitive test for detecting early breast cancer (greater than 95% in some studies).

As a result, of these studies the American Cancer Society (ACS) has revised its recommendations regarding breast MRI.  Its most recent guidelines published in 2007 recommend MRI screening in addition to mammography for women who meet one of the following criteria:

They have a BRCA1 or BRCA2 mutation

They have a first-degree relative (parent, sibling, child) with a
BRCA1 or BRCA2 mutation, even if they have yet to be tested themselves

Their lifetime risk of breast cancer has been scored at 20%-25% or greater, based on one of several accepted risk assessment tools that look at family history and other factors

They had radiation to the chest between the ages of 10 and 30

They have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or may have one of these syndromes based on a history in a first-degree relative

As expressed by Christy Russell, MD, Chair of the ACS Breast Cancer Advisory Board, “These guidelines are a critical step to help define who should be screened using MRI in addition to mammography, a question of significant importance as we discover women at very high risk of breast cancer can be diagnosed much earlier when combining the two technologies rather than using mammography alone.”