Is a Mammogram Enough?
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Is a Mammogram Enough?

Digital mammograms. Ultrasounds. MRIs. To stay healthy and protected, here is what you need to know about the new breast-cancer screening options.

Start with a Mammogram

Once you hit 40 -- sooner, if you're at high risk -- doctors recommend that you get a mammogram every year. There's no question that the test saves lives. In fact, when the number of women over 40 having mammograms doubled between 1987 and 2000, the jump was linked to an estimated 5,000 fewer breast-cancer deaths per year.

But while the should-you-or-shouldn't-you question is no longer debatable, other new considerations may now complicate your decision. Do you opt for a traditional film mammogram, the most widely available, least costly type? Or should you make sure you get the newer digital mammogram? Should you request an MRI or ultrasound for even-more-detailed images? Use our guide to decide what makes sense for you.

Start with a Mammogram

No matter what else you do, get an annual mammogram. The first one you have -- as soon after age 40 as possible -- becomes your baseline. (Since you'll probably switch doctors over the years, get a copy of the report and image for your home medical files.) As most women who have had one know, mammograms can be uncomfortable; even the digital kind requires compressing your breast between two plates while it's x-rayed, albeit for a very short time. (Younger women whose breasts swell before menstruation can minimize pain by scheduling the test shortly after their period.)

Conventional mammograms store the images on film, where they cannot be altered or manipulated. Digital tests, on the other hand, create an electronic image that can be enhanced by computer for an even closer look at possible problems. The catch? Three out of five breast-imaging centers still don't offer digital mammograms, and they cost more (a low average of $134, compared with a low average of $83 for film, says the American College of Radiology). According to Etta Pisano, MD, director of the Biomedical Research Imaging Center at the University of North Carolina School of Medicine at Chapel Hill, the digital picture is more accurate at detecting breast cancer if you fit into one of these three categories: You're under age 50, you have not gone through menopause, or you have dense breasts that make it harder to find cancer using x-rays. If that's not your situation, a film mammogram will detect cancer just as well as a digital one, says Dr. Pisano, who was lead investigator of a study of more than 49,000 women that compared the two types. For maximum accuracy, use an imaging center that performs a lot of mammograms -- or sends them out via computer to be read by mammography experts.

Do You Need Further Screening?

For many women the answer is no. But if you have dense breasts or risk factors such as a personal history of breast cancer or a previous abnormal biopsy, talk to your doctor about whether you might benefit from additional testing for cancer that mammograms can miss. There are two options -- MRI or ultrasound -- and a lot of debate about who really needs them. The good news? Neither exposes you to harmful radiation.

MRI: A "must" for a few. Of the two tests, MRIs find more cancers than ultrasounds. The American Cancer Society (ACS) recommends a screening MRI in addition to mammography only for women with a high personal lifetime risk of breast cancer (doctors evaluate this according to specific criteria), the BRCA1 or BRCA2 breast-cancer genes, a strong family history of breast or ovarian cancer, or a personal history of chest radiation therapy.

During an MRI you lie on a table that slides into the center of a cylindrical tube where a powerful magnetic field and radio waves produce a detailed computer picture of the breast tissue. You may also get a contrast agent through an IV to improve the image. The procedure is otherwise painless but costly: a low average of $1,072 for both breasts. Insurance may not cover the cost, especially if you don't fit ACS guidelines. Some women get claustrophobic in the machine or say it's hard to lie still for 30 to 60 minutes as it thumps and hums around them.

Ultrasound: An Alternative? Early results from a three-year study of more than 2,800 women nationwide found that adding an ultrasound (low average cost: $87) to a screening mammogram was better than a mammogram alone at finding cancer in those with a higher-than-average risk of it.

The reason? Both cancer and breast tissue show up as white on a mammogram if you have dense breasts. "It's like trying to see a polar bear in a snowstorm," says Wendie Berg, MD, PhD, a radiologist at an outpatient center affiliated with Johns Hopkins Medicine and the study's lead author. But on ultrasound, cancers are usually darker than surrounding tissue.

There's a drawback, though. Adding ultrasound to mammography notably increases the rate of false-positives, when the test red-flags something that turns out not to be cancer. One in 10 women in the study had a biopsy that didn't find cancer. "That's a lot," says Dr. Berg. Some women find these odds unacceptable, while others tolerate the risk because the test ups the chances of finding cancer. Doctors are also divided on this issue. "The evidence so far suggests that for women at highest risk for breast cancer, MRI is superior to ultrasound," says Carol H. Lee, MD, chair of the American College of Radiology's Commission on Breast Imaging, who also prefers it for those at lesser but still higher-than-average risk.

Breast Test: How Dense Are Yours?

You can have dense breasts whether you hook up a D-cup bra or fit into an AA. The size and shape of your breasts don't provide much of a clue to the kind of breast tissue you have. Instead, "breast density" refers to the amount of different kinds of breast tissue you have. The denser your breasts, the greater your chance of developing breast cancer, even when other risk factors are absent. Every woman falls into one of four categories, from the least dense ("mostly fatty") to the most ("extremely dense"). Mammogram results now routinely note this crucial information, so ask your doctor where you are on the spectrum.

More than half of women under 50 and almost a third over 50 have somewhat-to-very-dense breasts. "For these women, digital mammography is significantly better than film," says Dr. Pisano.

If You Have Implants...

If you have breast implants, be aware that they block a clear view of tissue that lies beneath them. When getting a mammogram you'll likely need four views of each breast instead of the standard two. "Either film or digital mammograms work well," says Lawrence Bassett, MD, section chief of the Iris Cantor Center for Breast Imaging at UCLA.

"When you call for an appointment, it's important to ask if the technicians and doctors have experience with women who have implants." If they don't, ask your doctor to recommend a facility that does. Also alert the technician to your implants before the test starts.

The Bottom Line

If your doctor says you fit the ACS guidelines, you should have an MRI, says Constance Lehman, MD, director of radiology at the Seattle Cancer Care Alliance and the doctor who cowrote them. Reports of other tests to spot breast cancer in its early stages have been in the news lately. Though they show promise, they are still experimental.

If you don't meet MRI criteria but have some risk factors and are willing to risk a false-positive, consider ultrasound. And remember that, as of now, neither ultrasound nor MRI can substitute for tried-and-true mammography, which is still "the only test that has proved to save lives with early detection," says Dr. Berg. "We want to augment it, not replace it."

Find a Breast Imaging Center

For help in locating a facility that has the most up-to-date accredited equipment, see either of the following Web sites:


Originally published in Ladies' Home Journal, December 2008.