Breast Cancer Screening

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Q: I am confused as to my mammogram options. There are digital and regular X-ray mammograms. What is the difference and which type is more effective? Also, is there a risk for false positive findings on these mammograms?

A:Mammograms are X-rays of the breast. They are used to check for cancer in women without breast symptoms (which is considered a screening mammogram), as well as in those with symptoms (diagnostic mammogram) such as lumps, changes in skin texture and appearance, pain, or nipple discharge. However, mammograms are not perfect and can miss 15 to 20 percent of breast cancers. That's why mammograms are often combined with other techniques, including clinical breast examination, ultrasound, and magnetic resonance imaging to detect breast abnormalities.

While regular mammography captures images on X-ray film, digital mammography stores images onto a computer. As a result, digital images can be made larger or smaller, lighter or darker, or separated into sections. While both screening tools have a similar ability to detect breast cancer for most women, the digital option may provide an advantage for women who have dense breast tissue (generally younger women or those on hormone replacement therapy), for those under age 50 and still have a period, or for those in their perimenopausal years.

What's most important is to get your mammograms taken in accordance with the latest screening recommendations, and to visit a facility known for quality and accuracy.

Preparing for your mammogram

As you get ready for your mammogram, take an active role. Here are a few suggestions:

Don't use deodorant, antiperspirant, lotion or powder on your armpits or under your breasts on the day of your examination. Certain ingredients in these products may appear as white spots or shadows on the mammogram.
If available, bring previous mammograms from another facility to your current testing site. This will help the radiologist compare past findings to the most recent results.
Try to schedule the mammogram for the week after your period, when your breasts are less tender.
Inform the person scheduling the mammogram if you are pregnant or breast-feeding before you are tested, as this may require changing the date of your mammogram.
Inform the radiologist if you have breast implants.
Inform the radiologist of any breast concerns (discharge, lump, pain, family or personal history of breast cancer, previous surgeries, etc.).

Screening for the early detection of breast cancer

The American Cancer Society and Susan G. Komen for the Cure make the following recommendations for early detection:

Women of age 40 and above should have a yearly screening mammogram. If breast cancer or gene mutations (BRCA1, BRCA2, etc.) run in your family, examinations may begin at an earlier age.
Arrange for a clinical breast examination (CBE) performed by your physician, nurse practitioner or other health care provider trained in this technique. Examinations should begin at age 20 with follow-up appointments every three years (as long as no abnormality is discovered) for women ages 20 to 39. After age 40, a CBE is recommended on a yearly basis. Please note this examination is in addition to a mammogram.
Learn and perform monthly breast self-examinations (BSE). While this technique is better at identifying changes in the breast that are more likely harmless than harmful, you should still get to know them and report any changes, including nipple discharge, any change in size, shape, feel or consistency of the tissue, or pain or tenderness, to your health care provider.

The role of magnetic resonance imaging (MRI)

Magnetic resonance imaging (MRI) is suggested, in addition to a screening mammogram, for women with a 20 percent or greater lifetime risk for breast cancer (this is considered high risk). The high risk category includes these indications:

A BRCA1 and/or BRCA2 gene mutation (obtained through genetic testing)
A close relative (mother, father, sister, brother or child) with a BRCA1 and/or BRCA2 gene mutation (even if you have not had this test)
A history of radiation treatment to the chest between the ages of 10 and 30
A history of genetic diseases such as Cowden syndrome and others for you or a close relative, as noted above

For women with a moderate lifetime risk for breast cancer, it's best to speak with your physician regarding the benefits versus the risks of MRI testing, in addition to a screening mammogram. Moderate risk indicators include the following:

A personal history of breast cancer
An estimated lifetime risk for breast cancer of 15 to 20 percent; your physician can use risk assessment models such as Claus and/or Tyrer-Cuzick or others to approximate this risk
A personal history of lobular carcinoma in situ (LCIS), ductal carcinoma in situ (DCIS), atypical ductal hyperplasia or atypical lobular hyperplasia
Dense breast tissue as noted on mammogram

Look for certifications of testing quality

The location where you are tested, whether mobile mammography screening van, hospital, private office, radiology facility, etc., should be accredited and certified by the Food and Drug Administration (look for their FDA certificate), and should maintain compliance with the Mammography Quality Standards Act (ask to see the MQSA certificate). Both certifications ensure the highest standards in safety and quality for the equipment, the physicist maintaining the devices, the technologist administering the mammograms, and the radiologist interpreting the tests. Additionally, MQSA standards require the testing facility to mail results to the patient within 30 days of their test (and sooner if an abnormality is present). Also, the wording in the letter should be understandable to those without a medical background.

To find out if your facility meets these standards, check out the certification requirements set by the Food and Drug Administration.

Test results

When interpreting test results, it may be best to go to a facility whose radiologists have additional training in the reading and interpretation of mammograms. Also, check the radiologist's experience. Radiologists who read a larger volume (more than 2,500 per year) of results may have a higher rate of accuracy.

However, be reassured that no matter what the number, the majority of certified facilities are of high quality. In fact, a good way to check quality is to ask about a facility's false-positive rate (initially interpreted as abnormal on a screening mammogram but later determined as benign after further testing with a more comprehensive diagnostic mammogram, ultrasound and/or biopsy). The acceptable false-positive rate is 10 percent, as dictated by the Agency for Health Care Policy and Research.

Lastly, don't assume no news is good news. If you haven’t received your results within 30 days of your procedure, take charge and call your physician to get your results.

Your physician is your best choice for personalized information on your unique needs for a mammogram. For additional information, try Susan G. Komen for the Cure, National Women's Health Information Center, and The National Cancer Institute.

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Robert Danoff, D.O., M.S., is a family physician and program director of The Family Practice Residency, as well as the combined Family Practice/Emergency Medicine Residency programs at Frankford Hospitals, Jefferson Health System, Philadelphia, Pa. He is the medical correspondent for CN8, The Comcast Network, a regular contributor to Discovery Health Online and a contributing writer to The New York Times Special Features. (Read his full bio.)