Why do they keep telling me to get mammograms?

It is my understanding that those with dense breasts should get an MRI. Also, shouldn't your breast surgeon, not oncologist, be directing what kind(s) of screenings you should have?

Just because your previous diagnosis didn't show up on a mammo doesn't mean that if you get BC again, it will be the same type of cancer and it will present in the same way.

Each type of screening is best at showing something different. Calcifications, which can be a sign of early stage breast cancer, rarely show up on ultrasounds and are best seen on mammograms. MRIs don't show the calcs but may - or may not - show the cancer that is associated with those calcs. I have extremely dense breast tissue but the calcs I've had in both breasts (one side benign, one side cancer) were visible on my mammos.

So mammos still have a role. As do ultrasounds and MRIs. What I don't understand is why mammos are always the first screening, as opposed to ultrasounds or a combination of a mammo and an ultrasound. I would think that ultrasounds are the least expensive screening method and yet there seems to be a reluctance to do them.

I'm several years out now. I get both mammos (now 3D mammos) and MRIs, alternating every 6 months (in other words, one mammo a year, and one MRI a year, 6 months apart). I get ultrasounds only when something is unclear or suspicious on either the mammo or MRI.

True "science" gets lost by standardizing.

I "get" it that mammograms are less effective with dense breasts like I originally had because they can't see the calcifications as well. So, why can't we come up with standardization that provides women with dense breasts the option of ultrasounds (plus I personally would throw in doing a relatively inexpensive test for a marker like a CA 15-3, since after all, mammograms and ultrasounds aren't "reliable" either for dense breasts; at least a marker that is out of line could at least serve as a trigger for using the more spendy MRI for some patients).

It is like we can't think outside the box once standardization has been in place for something like mammograms.

I am a good example. Tamoxifen got rid of my breast density within 3 months of starting treatment. That helps to see better whether I have calcifications. I happen to be over 10 years out and HR+ with no recurrence. So my BS has now classified me into a category in his mind where I must have yearly mammos AND yearly MRI's, alternating every 6 months. But... I thought the MRI was used for dense breasts???  Go figure.

Here's what the breastdensity.info site says about mammograms:

Q: Should my patients who receive this letter and have dense breasts continue to get mammograms?

A: Yes. Mammography is the only screening tool that has been demonstrated through large randomized trials to lower breast cancer mortality. Those trials included all breast densities. While mammography sensitivity is somewhat lower in women with extremely dense breasts, it is still the best modality for population-based screening. Also, mammography is the only test that can reliably detect suspicious calcifications. Such calcifications are often the first sign of in-situ cancers, which (in 20% of cases) coexist with otherwise invisible invasive cancers.

And here is what they say about other screening methods:

• For patients who are interested in additional screening options, a breast cancer risk assessment may be appropriate. It is a good starting point in the discussion of whether supplemental tests will be beneficial and what tests, if any, to order.

• The other breast imaging "screening options" include screening MRI, ultrasound and tomosynthesis ("3D mammography"). Screening breast MRI has been shown to substantially increase the rate of cancer detection. It is recommended in patients who are at very high risk (>20% lifetime risk) based on American Cancer Society guidelines. For patients at "intermediate risk," such as those with a personal history of breast cancer or a prior biopsy diagnosis of atypia (equivalent to a 15% to 20% lifetime risk), a patient-centered shared decision-making approach is recommended.
• Screening breast ultrasound is not offered at many centers and may entail an out of pocket charge to patients. Small studies have shown a modest increase in cancer detection, but also a high rate of false positives resulting in benign biopsies. The choice to have this test should be made on an individual basis after a discussion of these risks, benefits, and costs.
• Breast tomosynthesis ("3D mammography") is being offered in addition to screening mammography in some centers. Thus far, we have preliminary encouraging data on the performance of tomosynthesis in women with dense tissue.

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This website is written by a bunch of breast cancer specialists and breast radiologists from a number of California medical centers and medical universities.

Alaska, I just cringe when I thing of all the CTs I had in a couple of months when I had ovarian cancer. A second hospital repeated some because they wanted their own, plus on the chest ct the imaging was poor and they put me right back in the machine thirty minutes later.

I very much agree, SpecialK. Health care providers see a never-ending stream of patients, and any help we can give them to be aware of the things that are key for us as individuals is meaningful -- even when the general "rules" might need to be reconsidered through having an intelligent discussion together.

MelissaDallas, I cringe in shared awareness, and am sorry you have to deal with it. When I had rads sickness I recognized it immediately. For 3 days straight, I could barely turn over in bed at night because of exhaustion, and I am quite active and mobile normally. I would get up in the morning and by noon I couldn't stand up because of exhaustion.

What stands out in my mind too is how easy and commonplace it is for health care providers to minimize it, not as a deliberately cruel or careless thing but as something they are not personally experiencing, and as something that is not happening to someone they know and love. My PCP is an excellent health care provider and very caring, but even he has some blind spots that occasionally still surprise me.

MelissaDallas,

Obviously, IF health care providers would provide us with the simple truthful protective measure of maintaining a running tally of our exposure, and then use that to compare outcomes for different diagnoses for different patients, the use of radiation would be based on a far more accurate predictable basis. I'm just sorry that they haven't made that effort in our behalf.

A.A.

falleaves - it was indeed interesting and kind of like one-stop shopping! I had not intended to spend the entire day there, but that is what happened - I liked that I did not have to wait for answers - I was right there as the pathologists told the surgeon that what they saw was not cancer. This was a number of years ago - at least 10, so they were ahead of their time in providing this! I just had a somewhat similar experience with civilian providers with MOHS surgery for skin cancer - my biopsy was positive but the surgery involved them removing a layer, getting immediate pathology, then continuing to remove layers until they achieved a healthy margin.

I hear ya on the frustration. I have had this discussion with my MO but they do not sway in their mammogram love. My mammograms have always been normal even when MRI and ultrasound have found idc, dcis, calcs, fibroadenoma, and about 5 other types of high risk leisions. I have given up arguing with them and I just get the annual mammogram. I am hoping that 2 years of Tamoxifen will kick in and decrease my breast density. It actually worries me that it hasn't yet. In the mean time, I am vigilant about getting my MRI.

FYI. An ultrasound missed my cancer too.

The breast density categories (or sometimes called "classes") were established by the American College of Radiology. They are called BIRADs density categories. These are different from the BIRADs ratings that are given to mammogram, ultrasound and MRI imaging.

BIRADs Density Category 1: <25% dense for almost entirely fatty

BIRADs Density Category 2: 25%-50% dense for scattered fibroglandular densities

BIRADs Density Category 3: 51%-75% for heterogeneously dense

BIRADs Density Category 4: >75% dense for the extremely dense

This study of over 7000 women found that "a majority of patients (57%) between the ages of 40 and 49 years had high-density breast tissue, and an additional 17% had very-high-density breasts." So that's 74% of women in their 40s who have 'dense' breasts.

Looking at other age groups, the study found that density levels "decreased to 49% high density and 8% very high density in women in their 50s. However, 44% of women in their 60s and 36% of women in their 70s still had heterogeneously or extremely dense breast tissue. In our smallest group, women 80 years old or older undergoing screening mammography, 41% had heterogeneously dense or extremely dense tissue"

The Relationship of Mammographic Density and Age: Implications for Breast Cancer Screening

I think those numbers put the density issue into perspective. Women are so scared to find out that they have dense breasts, without realizing that it's actually normal to have dense breasts, particularly in your pre-menopausal years. That's not to say that extra diligence and extra screening isn't necessary for those with dense (and particularly, extremely dense) breasts, but I don't think it's as scary when you realize how common it is - and when you realize that all the breast cancer risk numbers that we read about (and are given by our doctors) already incorporate breast density into the numbers.

As Alaska Angel said (and others), ultrasound is not used routinely as part of breast cancer screening because it is so labor intensive. In the United States it is not routinely covered by insurance. I believe that it is actually slightly less expensive than mammography (and definitely less expensive than the newer mammographies-3D). There was a flurry, a few years back (before the "Are You Dense" movement) of women asking for ultrasound as part of their screening, after the actress, Suzanne Somers, discussed how her breast cancer was missed on mammography. I asked for ultrasound for a number of years (with a history of atypical ductal hyperplasia), and then my surgeon said that the ultrasounds had lots of false positives, so I stopped doing it routinely (only if they found something on mammo and they wanted to do ultrasound afterward.)

Fast forward. Now 14 states have passed Breast Density Notification Laws, requiring radiologists to note breast density on the mammography report. Mine always mentioned extreme density for years, so I already knew it. Anyway, the law doesn't mandate use or payment of ultrasound, it just mandates notification to the patient. It is up to the patient to request ultrasound or MRI. I have done just that (for ultrasound).. I was surprised that it wasn't offered to me this past year. I had already had the DCIS diagnosis, and the protocol for follow-up was for mammography ONLY, no ultrasound and no MRI, and yearly, at that. This is at an esteemed cancer center in the US. The surgeon had told me (concurring with Beesie and others) that the calcifications DO show up well on mammography, usually. She had also told me that small solid tumors show up well on ultrasound. Ironically, she still didn't ask for ultrasound, but I was able to do so myself, when it came time to scheduling. It's covered by the insurance due to the diagnosis (and due to the fact that the surgeon ordered it--at my suggestion). We need to be proactive. I'm not crazy about no MRI follow-up, but I've gotta live with it. At least, I did get MRI's as part of the initial diagnostic work-up, which some women have to fight for.

Fallleaves--about the radiation exposure, I can tell you that I had nearly CONTINUOUS mammos for about half a day once, when they were trying to locate an area of concern for surgical biopsy. I was already "pinned up" on the right side for a wire-guided excisional biopsy, and they were looking for something on the left. The radiologist tried over and over and over again. I was very concerned about the excess radiation exposure. She finally gave up, and then they tried to locate the area by ultrasound, and poked around (literally poked with needles) also for a long period of time. Finally, they gave up. I had the original films re-read by an outside radiologist, and discovered that they were looking in the wrong place (!). After all that, it must have been a cyst, because the problem never reappeared. I definitely stalled in getting my next mammogram after than experience. Anyway, as Beesie said, it's good to continue to get the mammograms, because it is possible that new tumors would show up on mammo, even if the previous one didn't. Also, the breasts usually do become somewhat less dense over time (even in the extremely dense group), especially with use of Tamoxifen or Aromatase Inhibitors.

I completely agree with you, Divecat, that size of breast, perkiness, etc. don't relate to density. I do have a question; however, and that pertains to surgery on breasts that are dense. I asked this before. I know that surgeon's can't feel or visually examine a breast and say if it's dense, but what about the "feel" with the scalpel. If density has to do with the density of glandular and connective tissue, then It seems that it would be harder to actually "cut" (sorry to be so graphic) the tissue. My surgeon, in one of the more recent surgeries, actually broke a couple of scalpels during my surgery (that's a scary thought). She told me this after I asked how the surgery went, especially with my very dense breasts. I was also awake during a much earlier excisional biopsy (the surgeon used local anesthesia), and actually felt the sawing and tugging. It wasn't easy to get through my breasts. So, it may be possible to sense whether someone has dense breasts during surgery (although clearly not foolproof). I guess we have to ask a knowledgeable surgeon (anyone?)

I had very dense breast tissue and all my doctors wanted mammo/US and MRI alternating every 6 months. I had been having mammo's for 14 years and my cancer did not show on mammo. On my one year followup mammo was clear and US found a lump. It was B9 but put me at high risk of cancer in that breast. At that time I said take them off and build me some new ones. The first time around it took 14 years to develop to cancer I just did not want to take a chance on going down that road again.