Intro: Duly Noted, a health and care podcast, is the official podcast series of Duly Health and Care. Each podcast features physicians or team members discussing groundbreaking topics and innovations that help listeners re-imagine and better understand an extraordinary health and care experience.

Jamie Lewis (Host): Many women know that the American Cancer Society suggests getting a mammogram to screen for breast cancer every year beginning at the age of 40. But what about women under 40? Under certain conditions, should they consider scheduling a mammogram too?

Today, I'm speaking with board certified radiologist, Dr. Kimberly Klinger, about risk factors, benefits, and limitations of early mammogram screening.

This is duly Noted, a health and care podcast from Duly Health and Care. I'm Jamie Lewis. Hello, Dr. Klinger. Thank you for joining me.

Dr Kimberly Klinger: Hi. Thanks so much for having me.

Host: I've heard many times that the average woman should start screening for breast cancer with annual mammograms at the age of 40. But for those under 40, are there any guidelines or recommendations regarding mammograms?

Dr Kimberly Klinger: So, while the guidelines provide a general framework for when women should start breast screening, screening has become increasingly individualized, taking into account a person's risk factors and their breast density. An initial breast cancer risk assessment, including family history, should be performed no later than age 25. And then depending on that individual's estimated risk and their breast density, you could consider starting screening mammography before 40 and/or adding any supplemental screening modalities to your screening regimen, such as breast MRI or whole breast screening ultrasound.

Host: Okay. Are there any risk factors or family history that might prompt a woman to consider getting a mammogram before the age of 40?

Dr Kimberly Klinger: Yes. Higher risk women may benefit from earlier screening as well as getting care at a high-risk clinic where the provider specializes in breast risk and breast clinical breast exams. For example, the people with a high lifetime risk of greater than 20 percent as determined by the risk models and the risk assessment, especially those who are either African American or Ashkenazi Jewish in descent. It's recommended that they consider starting annual mammogram by age 30 by the American College of Radiology. Other women that they recommend starting screening as early as 30 include women with genetic mutations associated with breast cancer, such as the BRCA1 or the BRCA2 mutation, or if you have a first-degree relative with any of those known mutations, also women with genetic syndromes associated with breast cancer or a first-degree relative with one of those syndromes. And those syndromes include Li-Fraumeni syndrome and Cowden syndrome to name a few.

Additionally, if you are a younger woman and you have a personal history of breast cancer or you have a personal history of a breast biopsy that's showing any type of atypical lesion such as ADH, ALH, or LCIS. The American College of Radiology recommends that you do annual screening mammography beginning at the time of your diagnosis or the time of your biopsy showing the atypia. And then, there's a special case for women who have had chest radiation for either lymphoma or some other type of cancer before the age of 30. For those women, the American College of Radiology recommends annual mammography beginning at age 25 or eight years after your therapy, whichever of those two ages is older.

Host: So, how effective are mammograms then in detecting breast cancer in younger women compared to older age groups?

Dr Kimberly Klinger: So, mammography is an effective screening tool at all ages. However, younger women, they typically have higher breast densities compared to older women. And dense breast tissue that is either breast density category C or D on your mammogram makes it more difficult to interpret a mammogram. And this is because the dense breast tissue can potentially obscure a cancerous lesion because both appear similarly white on the mammogram image. So because of this, the sensitivity of mammography in younger women with dense breasts is somewhat limited compared to older women who typically have less dense breasts.

Host: Okay. What are the potential benefits and potential limitations of starting mammograms before the age of 40?

Dr Kimberly Klinger: The main benefit of mammography is early detection of breast cancer at a time when it is the most curable, and that's the main goal of the screening programs. Limitations of mammography, the main ones include false positives, which is finding an area on the mammogram that is of concern, but that is not cancer, but requires additional imaging evaluation or biopsy. And coupled with this, there could be increased patient anxiety regarding getting called back from screening, additional testing biopsies, additional procedures and the wait time associated with those. There's also a minimal radiation risk exposure with the mammograms, but this is less than approximately two months of background radiation for each mammogram and technology is so good now that it's a very low dose.

Host: Yeah. For my part, I've always assumed mammograms are the only way to screen for breast cancer. But are there any alternative methods or imaging technologies that can inform younger women with specific risk factors?

Dr Kimberly Klinger: Mammography remains the primary screening modality for all women. And in addition to mammography nowadays, most mammograms are being performed with digital breast tomosynthesis or 3D mammography. And that is also helping with earlier cancer detection in women with dense breasts, including younger women.

In addition to just mammography with the 3D mammography, the most common alternative screening or supplemental screening modalities are whole breast ultrasound and breast MRI. So, supplemental screening ultrasound should be considered for average risk women with dense breasts, that is category C or D. And for women with elevated lifetime risk of breast cancer, regardless of their breast density supplemental screening, breast MRI should be considered. And it's actually recommended to start MRI screening in some of these high-risk women even earlier than starting screening mammography. So in many of the high-risk groups, it recommends starting screening mammography at age 30. But these similar groups of women may benefit from having an annual MRI screening between age 25 and 30. And those groups, as mentioned previously, include women with a high lifetime risk of breast cancer of greater than 20%. Those with the known genetic mutations or genetic syndromes or a first-degree relative with one of these syndromes, and women with a personal history of chest radiation before age 30. Also, similarly to the recommendations for starting mammogram early, younger women who have a personal history of breast cancer or a personal history of a high-risk atypical lesion should also consider starting that MRI screening, alternating with their screening mammogram at six months intervals beginning at the time of their diagnosis.

Host: We're talking a lot about breast density. It's coming up a lot. How does breast density impact the accuracy and the necessity of mammograms for women under 40?

Dr Kimberly Klinger: Increased breast density decreases the sensitivity of mammography, as we kind of touched on previously, because of the dense breast tissue looking similar on the mammogram to cancerous lesions, potentially obscuring them. But regardless of that, mammography remains the primary workhorse in breast screening and the digital breast tomosynthesis, or also known as the 3D mammography, has increased the accuracy of the mammograms, especially in the dense breasts. So women with dense breasts are overall higher risk for breast cancer because of their breast density than those without dense breasts. So, this makes screening ever more essential in these women. Breast density is considered also in all of the risk assessment models, and in that way, it can impact a person's screening initiation time and decision to utilize any supplemental screening modalities.

Host: That makes sense. Are there any potential drawbacks or risks associated with mammography in younger women that patients should be aware of?

Dr Kimberly Klinger: These are similar to the risks that were touched on previously. There aren't really any specific risks associated for younger women only that aren't just in general for the whole population undergoing mammography. And those include those false positives, the patient anxiety and the minimal radiation exposure.

I will add to that, though, that younger women starting screening before the age 40 are typically higher risk women, and they're also more likely to have dense breasts. So, because of this, there is potential to have more false positives in this population than the average population. But I think that the benefits of early detection, especially in young women, outweigh the minimal risk of the additional imaging and the potential biopsy procedures.

Host: All right. So for women who want to know more, how can they educate themselves about their breast health and make informed decisions about mammograms ahead of their 40th birthday?

Dr Kimberly Klinger: The biggest determinant in deciding when to start screening and if any, supplemental screening modalities you can use to augment your screening is knowing your personal estimated risk. So to determine your risk, there are some factors that contribute to going into the risk calculations that will be helpful to know and making sure that you are talking to your primary care doctor or some physician before age 25 to have your breast cancer risk evaluated is also essential in making sure that you're getting adequately screened.

Important aspects to know that help determine your risks include your family history of breast cancer and ovarian cancer; any presence the genetic mutations or syndromes; your menstruation history, meaning when you started menstruating and when you stopped, if applicable; your obstetric history, also with the ages of your pregnancies is important to know; if you are or have used any hormone replacement therapies; and your personal history of biopsies, especially paying attention to any biopsies that are showing atypical lesions; or your personal history of breast cancer also plays into the risk assessment, and your breast density, your age, and your race and ethnicity.

Host: Great. Thank you, Dr. Klinger. I appreciate all the education for listeners on this very important topic.

Dr Kimberly Klinger: Thanks for having me. I'm glad I was able to talk about this. I think it's important for women to know their risk, to know their breast density, and utilize the mammography and supplemental screening as applicable.

Host: I'm Jamie Lewis. And this is duly Noted, a health and care podcast. If you think this episode would benefit those in your social media channels, be sure to share it with them. To schedule an appointment with a doctor to discuss issues of breast health or to learn more, visit dulyhealthandcare.com.