Caitlin Whyte (Host): This is Putting Your HealthFirst. I'm Caitlin Whyte. And with me is Dr. Sharon Noori, a breast surgeon and oncologist from HealthFirst. Today, we will be talking about why 40 is the gold standard for mammograms.

Well, let's start with the big question of our episode here today. Why did age 40 officially become the gold standard for starting mammograms? And why did major health organizations recently update their guidelines to align with this?

Dr. Sharon Noori: So, there's been updated evidence in modeling supporting a favorable balance of benefits and harms starting at age 40 that prompted a standardized recommendation in 2020 form. Generally speaking, the harms of starting 40 versus 50 include false alarms, unnecessary biopsies, and overdiagnosis.

So, overdiagnosis means finding cancers that would have never really caused illness. What we have to compare is that if we start at 50, we're waiting longer, we have fewer false alarms, and the technical term for false alarms is false positives. But some cancers will be diagnosed later. Versus if we start at 40, we're going to have patients undergo more screening, may end up with more false alarms, but there's more opportunity to catch cancers before they become advanced

Host: Of course. Well, statistically, how much of an impact does starting screenings at age 40 have on long-term survival rates compared to waiting until 50?

Dr. Sharon Noori: So generally, we think that we prevent 1.5 additional deaths per 1,000 women when we start screening at age 40 versus 50. So, that number is relatively small, but there is definitely an uptake in the incidence of breast cancer in women above the age of 40. It's not as prevalent, when you compare women who are older in their fifth or sixth decade of life. But we certainly do see a rise in women after age 40.

Host: Well, with that, how important is it for women to get checked every year? And then, at what point should men also get checked?

Dr. Sharon Noori: There are various features and factors that can affect our sensitivity, reliability, and accuracy of imaging. And there are times we're looking for very slight or minor changes. When we have a patient who undergoes the annual mammograms, we are able to tell differences fairly early on, versus women who have not undergone the recommendations and all of a sudden present with a larger mass. It's harder to predict how long that mass or cancer has been there.

We don't really have an imaging protocol for men. Men should just be made aware that there is a possibility of them developing breast cancer. But mostly, the breast cancer in the male population is diagnosed after a noticeable or a palpable mass.

Host: We often hear that about one in six breast cancers are diagnosed in women in their 40s. Is breast cancer in younger women structurally different or more aggressive than in older women?

Dr. Sharon Noori: I would say on average, breast cancers in younger women have a different mix of tumor biology and are more likely to have aggressive features. The major molecular families, hormone receptor-positive, HER2 negative, and the more aggressive subtype of breast cancer, triple negative, can behave very differently.

So when we compare younger versus older patients, we find that younger women are more likely to have higher grade, more aggressive, higher proliferative rates type of cancers. Those are a little bit more complicated to treat. So, early detection of those cancers remains the goal.

Host: Well, how much smaller is a lump detected by a mammogram compared to one that can be felt during a self-exam?

Dr. Sharon Noori: The goal of the mammogram is to diagnose a cancer when it's roughly half the size of what we would normally feel. So for most patients, and again, there's various factors determining how easily we can feel a malignancy. But for most patients, we're not really able to notice or palpate a cancer or a mass until it's about two centimeters or so.

The mammogram is intended to diagnose a smaller, typically less than one centimeter, so half the size of what we would notice on a physical exam. Also, mammogram can diagnose even earlier processes, can identify the very beginnings of breast cancer with tiny clusters of calcifications or architectural changes. Those types of findings are really not noticeable on a clinical exam.

Host: And from a surgeon's perspective, how does catching a tumor at age 40 alter the treatment options?

Dr. Sharon Noori: Well, I think when we are evaluating younger patients, there are several additional factors to consider when we're trying to come up with a surgical and a medical plan. Those factors include genetics or hereditary predispositions. We see genetic mutations, more commonly in younger diagnosed patients.

Also, younger patients tend to have higher breast density, which again can affect the accuracy and reliability of imaging surveillance for future imaging purposes. Couple of different factors as it relates to medical treatment is going to be fertility and family planning consideration that may be altered by some of our medications.

And then, I would say there is going to be some cosmetic outcomes and changes that affect younger women more so than our older patients.

Host: Then, why do mammograms remain the undisputed gold standard over other technologies like breast ultrasound, MRIs, or thermography for general screening?

Dr. Sharon Noori: So, going back to advantages of annual mammogram, mammogram will oftentimes pick up changes such as calcifications or distortion that cannot really be evaluated by an ultrasound. Also, bear in mind that sonography and ultrasound is technician-dependent, where you're relying on the technician who is doing the ultrasound, whereas mammogram is a machine, and it can be reproduced at different facilities.

So if you get a mammogram here in Florida and then move to Texas, it's better to compare mammograms because it's being done by a machine versus ultrasound. So again, when you're trying to pick up small changes, having mammogram is definitely more reliable. I do utilize MRIs frequently for evaluation of my newly diagnosed cancers or my high-risk patients, but it's really not necessary for your average-risk woman because MRIs are highly sensitive and are known to cause false alarms

Host: Can you also explain the difference between a standard 2D mammogram and a 3D mammogram? And should patients actively request the 3D?

Dr. Sharon Noori: Yes. So, 2D mammogram just compresses all the breast tissue into a couple of flat images, whereas 3D allows the radiologist to scroll through thin slices of the breast tissue. So, 3D is more like a CAT scan of the breast. It gives the radiologist a lot more images to review, and it has been shown to be especially beneficial in women with denser tissue, and hopefully reduce the number of false positives or callbacks.

Host: And to wrap it up for us today, Doctor, if you could tell a woman in her 30s and 40s one thing about mammograms, what would it be?

Dr. Sharon Noori: I think there is a lot of misconception and fear about mammogram regarding how much discomfort they cause. There are women who have certainly more sensitive breasts than others. But typically, your average mammogram is about 10 to 20 minutes, depending on how many images or angles they need to do. It's bearable. It's manageable even for those with sensitive breasts.

I don't recommend the average risk woman in her 30s to undergo mammograms, but they should be very self-aware of their breast exams and any changes that they may notice. For women in their 40s, again, I support annual mammograms starting at age 40. There's not necessarily an upper age limit to when you can stop. It really just depends on the patient's health.

I think the other common misconception is radiation exposure. There is radiation exposure with mammography, but it's fairly minimum, and we probably get more exposure in our daily life, including traveling. There's more radiation that you get from flying to Florida, let's say California, than your typical mammogram. It's a very safe, reliable image. That's been a key component in diagnosing early breast cancer, which equates to better treatments and longer survival.

Host: That was Dr. Sharon Noori. If you're ready to schedule a mammogram, we hope this episode gives you confidence and clarity. For more information, go to hf.org/breasthealth. I'm Caitlin Whyte, and this is Putting Your HealthFirst. Thank you for listening.