When Katie Couric recently revealed she had been diagnosed with and treated for Stage 1A breast cancer, she recounted that she was six months overdue on her annual mammogram and shuddered to think what might have happened if she had put off the screening longer.
Ironically, however, due to Couric’s age, 65, some leading cancer organizations do not recommend women her age get a yearly mammogram if they are at average risk of getting breast cancer (for example, they don’t carry the breast cancer gene or have a family history of the disease and have not already had breast cancer – conditions that Couric did not say applied to her.) This is despite the fact that one out of eight women will get breast cancer in their lifetime and the risk increases with age.
As example, while the American College of Radiology recommends annual mammograms for women until 74 or beyond, the American Cancer Society says women 55 and older can switch to a mammogram every other year or continue with their annual screening. The U.S. Preventative Services Task Force, an independent panel of national experts in disease prevention and evidence-based medicine, recommends screening every other year starting at age 50.
So, while Couric’s doctor scheduled Couric for yearly mammograms, another physician using another protocol could have recommended them every other year. Then, Couric would have waited even longer for her screening, possibly allowing the tumor to grow larger and/or spread to other areas of her body and making the cancer harder to treat. (Couric’s Stage 1A tumor, the earliest stage of breast cancer, was confined to her left breast, which was treated successfully with a lumpectomy and radiation.)
Experts also disagree on when a woman should start getting a mammogram. Opinions range from age 40 (the American College of Radiology and the American College of Obstetrics and Gynecologists ) to 45, with the option of getting a yearly screening between 40 and 44, (The American Cancer Society) to 50 (the American Academy of Family Physicians).
Yet age is just the tip of the iceberg about conflicting opinions on breast screenings, further brought to light by Couric’s discussion of her dense breasts. Nearly 50% of American women over 40 who get mammograms have dense breast tissue, which research has shown increases the risk of breast cancer.
Because of Couric’s dense breast tissue, she received a 3D mammogram (also known as a digital breast tomosynthesis) rather than the standard 2D mammogram. In 2D mammography, two X-ray images are taken of each breast, one from the top and one from the side. A 3D mammography takes multiple cross-sectional images of the breasts from several angles, improving cancer detection up to 40% more than 2D mammography. A 3D mammogram is even more crucial for women with dense breasts because on a 2D mammogram, dense breast material shows up white, as do tumors, and it is harder for radiologists to detect the difference between cancer and normal breast tissue.
While 3D mammography is becoming more routine, it is not standardized care yet in the United States. Only approximately one-third of certified mammogram facilities offer 3D mammography. And opinions in the field vary as to if such technology is even needed. For example, the U.S. Preventative Services Task Force states that there is not enough evidence that 3D mammograms improve outcomes to recommend them for dense breasts, while the American Society of Breast Surgeons prefers 3D modality for women with dense breasts. Once again, Couric’s course of care may not be what other women in her situation experience.
Couric’s diagnosis brings up yet one more issue without general consensus – additional screenings for women with dense breasts. Couric received a breast ultrasound, which uses sound waves to see inside the breast in addition to a 3D mammogram. Women with dense breast tissue with a high risk of breast cancer may be offered the Magnetic Resonance Imaging (MRI), which offers the most detailed view of the breast of all screenings.
Such extra screenings, however, are not universally advised. Some organizations such as the American College of Radiology recommend them in certain situations, but others, such as the American College of Obstetricians and Gynecologists do not, the general thinking being that research does not show that extra or different screening methods reduce breast cancer deaths in these women.
(A good source that provides a snapshot of varying recommendations by seven leading organizations for not only additional breast screenings but mammograms can be found on the CDC website.)
While the field may not agree on the timing or type of breast screenings, all medical organizations do agree that regular screenings are key for a woman’s breast health. Still, the differing standards of care can cause confusion among both providers and patients. In the absence of a Holy Grail of truth, what are women to do?
October being Breast Cancer Awareness Month, now is a good time for women to research different types of screenings and talk to their care providers so they can be fully informed about all of the options available to them. They can then ask for the screenings that best suit their personal health needs and history and find a breast care facility that will accommodate those needs. At Keck Medicine of USC, for example, where I work as a breast cancer radiologist, we take the most proactive approach to screenings. We recommend all women receive a yearly 3D mammogram from age 40 on up, and that women with dense breasts receive an additional annual ultrasound or MRI.
The bottom line for women is, it’s your body and you are the ultimate expert in it. Working in tandem with a trusted care provider, you must be your own advocate for receiving the best and most personalized care.
Linda H. Larsen, MD, is a breast cancer radiologist with Keck Medicine of USC and the director of the Division of Breast Imaging at the Keck School of Medicine of USC.