Transcription:
Mammograms: Understanding the Latest Recommendations

Melanie Cole (Host): For years the American Cancer Society urged women to start mammograms at age 40, but they’ve recently changed their guidelines and there’s been some confusion as to when is the best time to start this very important screening. My guest today is Dr. Jeff Matthes. He’s a radiologist with Lincoln Radiology Group. Welcome to the show, Dr. Matthes. Tell us about a woman’s risk for breast cancer as it stands now.

Dr. Jeff Matthes (Guest): Thanks, Melanie. In general, on average, one out of eight women will develop breast cancer at some point in their life. Still, the average is women over the age of 60 are more likely to be diagnosed with breast cancer, and only maybe 10-15% of breast cancer occur in women younger than 45.

Melanie: Is there a genetic component? What are the risk factors, lifestyle modifications--things that women need to know that put them at risk?

Dr. Matthes: There are genetic components, although, still, the vast majority of breast cancer is non-familial and non-genetic based, but certainly I think a lot of people know about the BRCA gene and are being tested for that, especially if you have a mother or an aunt or a sister, especially if they’ve developed breast cancer in the premenopausal years. Testing for genetics is important because that puts a patient at a much higher risk, not just for breast cancer but also, depending upon the factors on the BRCA gene, at a higher risk for ovarian cancer as well.

Melanie: All women have the BRCA gene, yes? It’s just a mutation of the gene that puts them at risk for breast cancer?

Dr. Matthes: Correct. And there’s two types of mutations, 1 and 2. When they say to have the gene test, that’s actually what they’re looking for--the mutation and not the gene itself because, you’re correct, all women should have that.

Melanie: So then, let’s talk about the screenings. Mammography has always been sort of the gold standard. Tell us about mammography and what’s going on in that world today.

Dr. Matthes: It’s pretty amazing, actually. Just in the last few years it has advanced significantly, and then, even in the last five years it has advanced even more rapidly. It started off where we used to just use a regular x-ray unit and take pictures of a woman’s breast with high-dose radiation. Then, they developed low-dose radiation for mammography because the gland is mostly fat, even though there’s a lot of glandular tissue in there. You can use a lower dose radiation and actually get better images. It went from that to what we call “film screen mammography” where they developed a screen that will block out certain amount of radiation so you could even more detail. Then, it went to digital mammography which allowed us to even use less radiation. And now, we have 3D digital mammography which currently is using 25% of the recommended dose of radiation that the government says is allowed. So, the new 3D digital mammography is fantastic. It allows a better image, multiple images, it’s similar to a CT scan through a woman’s breast at one-fourth the amount of radiation that we used to give, even just a few years ago.

Melanie: How do we know whether we need a 3D or a 2D or an ultrasound. How do you know which type of screening that you need?

Dr. Matthes: First of all, this should always start with a patient’s primary care physician, whether that’s family practice doctor, obstetrician, gynecologist, internal medicine doctor, and, in some patients’ case, it’s going to be a physician’s assistant or a nurse practitioner. Certainly, they should always seek their advice and go through that route to get to me, basically. But, in general, on my end of it I think all women should have a 3D digital mammogram because it’s the same or, in many cases, less radiation than a regular 2D mammogram but you get a lot more information. And, in general, I think the country is rapidly moving towards 3D mammography. In Lincoln alone, you’ve seen we had the first unit, then the second unit, and now we’re seeing everybody around us also purchasing 3D mammogram machines, because it has become the gold standard very quickly.

Melanie: Who should have it? At what age? What are the recommendations right now, Dr. Matthes?

Dr. Matthes: They are across the board. I guess what I will do is start with the American College of Radiology, since I’m a radiologist, and our recommendations really haven’t changed in a woman with no serious risk factors, meaning first degree female relatives, mother, sister, aunt, in an average woman who doesn’t have any known risk factors patients start at about the age of 40 getting an annual mammogram. The American Cancer Society recently changed their recommendation saying from 40 to 44 years of age, it’s a woman’s choice or a clinician and a woman’s choice together. From 45 to 54, every year, and from over 55, they are now saying every two years. But, that’s their assumption is that most women have menopause by age 55. The problem I have with some of these recommendations being lengthened out that way is that they’re based on clinical data that includes data going all the way back to what I talked about when we used to take mammograms of a woman with film screen mammography or even plain radiographic images of a breast, and the field has moved more rapidly than the research as far as early detection and ability to see a small lesion. So, these recommendations are always kind of behind what’s really happening on the home front. So, it’s confusing to women and I can understand why, I’ve got a wife and four daughters, but, at the end of the day, I think the most important thing is that, once again, a woman sits down with her primary care provider and asks for their advice as well. We have a very good relationship with most of our primary care providers who refer to us, they don’t hesitate at all to pick up the phone and just call us and say I’ve got this patient, and here’s this situation, what would you recommend?

Melanie: So, Dr. Matthes, once we get the mammogram, a 3D, whichever one we get, then do we still sit in the office and wait to hear that we have to come back in for new pictures or that dreaded letter that says that we now need a diagnostic? How does that all work, because that’s a tense time for us.

Dr. Matthes: Yes, it’s very stressful. I will say that, in general, and especially at Bryan, we follow our statistics very closely. Ten percent of women will get called back. So, 90% of women have a screening mammogram, that’s it, they have the mammogram, it’s finished and it’s over. At Bryan, for instance, all of those are interpreted within the same day. So, by the end of day any woman can get on their patient portal and login with their secure ID and read their mammographic report. So, 90 percent of women who have a screening mammogram will never get called back. 10 percent will get called back and they may need extra mammographic views and/or an ultrasound depending upon what the finding was, whether it’s classifications or density or if it looks like it might be a mass. So, that’s hard to tell somebody ahead of time in a blanket statement what you’re going to have when you come back, but you will have some kind of additional imaging. With 3D mammography, for instance, we see enough detail that oftentimes, a woman comes back simply for an ultrasound, not additional mammographic use, which I like because there’s no extra radiation involved, the ultrasound is sound wave, not harmful, and it’s quick and easy and safe. That being said, of all screened mammographic patients per year, only one to two percent will actually proceed to an actual biopsy. And, in that case, less than half of those are actually going to be positive for cancer.

Melanie: That’s great information, very helpful for women. You mentioned dense breasts. There are laws in the country about that, right? You have to let women know if they have dense breasts? Tell us about that.

Dr. Matthes: Yes, the laws actually vary a little bit from state to state, and California have led the way. They’re very strict as far as having to report the dose, and so we just decided this was going to happen eventually even in Nebraska, and so we report the dose that a woman needs. It’s an inverse way of looking at how dense the breast is, how much radiation is required to penetrate the breast is kind of a factor of how dense it is. Women that have dense breasts, many times will know that. They can feel that they have dense kind of plumpy, bumpy, dense breast tissue. And, on the flip side, women who don’t have dense breasts know that, too, they’re move movable and what not. But, the important thing about breast density is that the denser a tissue is, the harder it is to see through it, which is why 3D mammography was developed in the first place. With the standard two-dimensional image, you basically get two views of each breast, one from top to bottom and one from side to side of each breast, so four total views. If it’s really dense, there can be something in the middle there that you don’t see. With 3D mammography, it doesn’t really matter. Even though the best issue is very dense, we’re going slice by slice by slice, by millimeters from top to bottom and side to side through each breast, so we have a hundred images not four images to look at. That really helps detect even small cancers. And, in fact, our experience at Bryan was that we detected several 3 to 5 mm cancers that you just could not see on the standard 2D mammogram. So, especially women with dense breasts or women with a high risk like a family history, we really strongly encourage the 3D mammography.

Melanie: In just the last minute, wrap it up for us. Really tell women what you want them to know, what’s very important about mammography and the risk for breast cancer.

Dr. Matthes: In general, it’s so well publicized that I’m surprised at how many women still don’t even get an annual screening mammogram. Occasionally, we still have women who wander in at the age of 70 because usually their children, usually a daughter, finally twists their arm to come in. I think that, by and large, a lot of women still are not paying attention to the high risk. One in eight women will develop breast cancer, so it’s really, really important to talk to your doctor or primary health care, whether it’s a PA or nurse practitioner, and discuss the risk factors and come in and get a mammogram and start the process of screening. It’s really more important that you have a baseline and then your further mammograms on down the line are what we can compare with to see a change. If you come in off the street, your baseline mammogram may look fine, but it’s the mammograms after that that we look at to see, oh, something is changing here, let’s get more views or let’s look at that more closely.

Melanie: Thank you so much for being with us today, Dr. Matthes. For more information, you can go to bryanhealth.org/mammography. That’s bryanhealth.org/mammography. You’re listening to Bryan Health Radio. This is Melanie Cole.