What to Know About Breast Cancer Screening: Q+A with Dr. Elise Desperito
Breast cancer screening, or checking a patient’s breasts for signs of cancer before the appearance of any symptoms, can help find the disease at an early stage when it can be treated and even cured. While medical experts agree that women should all get screened at some point, the age at which screening should begin is an area of controversy and disagreement, leaving patients confused as to what they should do.
For example, the U.S. Preventative Services Task Force (USPSTF) recommends that women who are 50 to 74 years old and are at average risk for breast cancer get a mammogram every two years. The American Cancer Society (ACS), on the other hand, states that women aged 45 to 54 years with an average risk of breast cancer should undergo annual mammography screening, while women aged 55 years and older may transition to biennial or annual screening. As a third opinion, the American College of Radiology (ACR) suggests annual mammography screening even earlier — starting at age 40 — for women of average risk.
“This is a very controversial area. Esteemed medical societies have very different recommendations, and patients are caught in the middle of this debate,” says Elise Desperito, MD, chief of breast imaging and associate professor of radiology at Columbia University’s Vagelos College of Physicians & Surgeons. “Patients are confused understandably, trying to understand what to do. Should I get my screening mammogram at 40? Or should I begin at 45? Should I get it yearly or every other year?"
Dr. Desperito, who has extensive experience in the care of women with breast cancer, sheds light on the latest in breast cancer screening and how patients can find out the best recommendation tailored to their individual needs.
How can women decide which breast cancer screening guidelines to follow?
We know from the data that if a woman follows the ACR guidelines and gets an annual mammogram from the age of 40 until 84, she’s going to reduce her risk of dying of breast cancer by 40% in her lifetime. That’s pretty remarkable. If a woman follows the ACS guidelines, she’ll reduce her risk of dying of breast cancer by 31%. And if she follows the USPSTF guidelines, she’ll reduce her risk by 23%. That’s a big difference and really important for a patient to consider when she is making this choice.
As women decide how they want to be screened — and this is a very individual decision that involves a conversation with their primary care doctor or their gynecologist —we know that 1 in 6 breast cancers are found in women ages 40 to 49. We’re screening because we want to find breast cancers at the earliest stage so that women don’t die from their disease. We know that if we can diagnose breast cancer at a very early stage, women have a 97% chance of living absolutely fine and cancer-free for the rest of their lives.
How should patients determine which type of screening is best for them?
All women, especially Black women and those of Ashkenazi Jewish descent, should be evaluated for breast cancer risk no later than age 30, so that those at highest risk can be identified and can benefit from supplemental screening. When a woman asks her doctor to determine her breast cancer risk, or asks for a referral to a specialist who evaluates breast cancer risk, she will then be able to determine what type of screening is best for her.
Are there certain populations of women that are more vulnerable to developing breast cancer earlier?
A report from the National Cancer Institute supported research showing that aggressive forms of breast cancers are common in younger African American/Black and Hispanic/Latino women living in low socioeconomic areas. These aggressive forms of breast cancer, such as triple negative breast cancer, are less responsive to standard cancer treatments and are associated with poorer survival. Breast cancer risk assessment at age 30 is particularly important for these women.
Given this fact, if we as a society support the USPSTF guidelines, we are really disadvantaging these groups of historically underserved women. Our duty as clinicians is to decrease the disparities that we see in our healthcare system, so the takeaway for me is we should really be supporting breast cancer screening starting at age 40 for all women and particularly these populations of women.
What about a woman who is considered high risk? How does that play a role in screening?
The definition of “high risk” is also a point of controversy. However, almost everyone agrees on a few points. Any woman who has been genetically tested for breast cancer and is positive is high risk. Any woman who has a first degree relative diagnosed with breast cancer, meaning a mother, sister, or daughter, is high risk. Any woman treated for Hodgkin’s lymphoma at an earlier age and received radiation to her chest is considered high risk. It is crucially important for these women to consult with our Breast Oncology physicians, who specialize in the care of high risk women, and to have a complete risk assessment and develop a plan for their imaging and care.
What is 3D mammography, and what are the pros and cons of having a 3D mammogram?
The U.S. Food and Drug Administration approved digital breast tomosynthesis, also referred to as 3D mammography, in 2011. 3D imaging provides a much more detailed understanding of a woman’s breast tissue.
Digital breast tomosynthesis (DBT) provides images of the breast in “slices” making some abnormalities easier to see. DBT increases the number of cancers seen without additional testing.
About 50% of women have what we would describe as dense breast tissue, and when a woman has dense breast tissue, the sensitivity of a 2D mammogram is decreased. Dense tissue makes it harder to find breast cancers, but 3D mammography is able to better identify cancers in women who have dense tissue. That’s been proven. For women without dense breasts, a 3D mammogram is still helpful. The real takeaway is that getting a mammogram, whether it is 2D or 3D, is better than not getting a mammogram.
What is the current recommendation regarding breast self-exams as a way for screening?
This question is complicated. Current medical literature does not support the efficacy of the practice and most medical societies and academies discourage breast self-exams.
However, I would argue that like anything we do in life, we need to be taught well. Most of us are not taught how to do a self examination on our breasts. The Maurer Foundation for breast health education provides step-by-step breast self-examination instructions featuring patient-oriented language and graphical representation of each maneuver. It is important for people to learn when and how to do a self examination so that it doesn’t lead to unnecessary imaging or increased anxiety.
We want people to be aware of their bodies and seek medical help when they identify something different or wrong. Just as we advise women to see their gynecologist if they are experiencing abnormal vaginal bleeding, we want women to see their gynecologist or primary health care provider if they think there is something different or wrong with their breast(s).
As a specialist, what’s on the horizon in breast imaging? What are you most excited about?
The integration of artificial intelligence (AI) and machine learning into our work is showing tremendous promise. AI is the use of analytics and data algorithms that help machines perform tasks normally associated with human intelligence. Current research is focused on helping machines develop these algorithms. Imagine how helpful it will be for a computer to analyze sets of mammogram images, evaluate patterns, and help indicate where breast cancers are?
Originally published in 2021. Updated in 2022 to reflect latest information.