Empowered to Choose: What Women Should Know about Screening Mammography

These days women are getting conflicting recommendations about when to start screening mammograms and how often to have them. I talked with breast surgeon Janie Grumley, MD, who says that a better understanding of mammograms as a screening tool and knowing how early detection impacts cancer treatment provides the best context for decision making.

Grumley, Janie Weng 11

Janie Grumley, MD

You say some providers are telling their average-risk patients that annual screening for breast cancer may be unnecessary. Why are some women hearing that going two or even three years between mammograms is OK?

Dr. Grumley:  Recent studies have been in the media that give conflicting information about screening mammograms. What’s important to understand is that all the experts agree there is a benefit to breast cancer screening. Where conflict lies is around the ideal interval for screening. Many of the studies focus purely on the rate of survival, but survival alone is not the only benefit. When cancers are found early the treatments needed to achieve survival may be drastically different compared to cancers found later.

The reason why some practitioners are recommending longer intervals between mammograms is an attempt to lessen anxiety for women undergoing screening. But that may come at a cost, if the result is later detection of cancer and possibly the need for more treatment. Instead, I think it is more important to educate women about the limits of screening mammograms so they better understand the process and are not alarmed when called back for additional tests.

Mammograms are not perfect tests and a percentage of women will get called back for more views, and may even require a biopsy. What would you tell women whose anxiety may be keeping them from getting a mammogram?

Dr. Grumley:  Here’s something women should keep in mind: A mammogram doesn’t see cancer cells. It simply helps us see differences in how the breast looks. So we take that first look, and sometimes pick areas that need a closer look. Even biopsies are done when something looks different, not because we know it’s cancer. Providers could do a better job of helping women understand that after a mammogram, there is always the chance they will be called back. And that just means we’re not sure of the nature of the change we’re seeing. A very small portion of the women that come back will need a biopsy, and a much smaller percentage will actually have cancer.

Doing a mammogram every year, beginning at age 40, is the ideal way to track subtle changes in breast tissue and identify problems early. It’s the series of mammograms that will give us the best information. It’s like weighing yourself one day, but not tracking your weight over time. It’s a very limited piece of information. Getting mammograms every year creates a more complete picture and helps us see what we need to see.

That said, breast cancer screening is not one-size-fits-all. If a woman has very dense breast tissue, for instance, the type of imaging is important. Somebody with very dense breasts should have 3D mammography, and possibly a screening breast ultrasound. Those with fatty breasts can have a good test with a 2D mammogram. So it’s also about selecting the right tool for the right patient.

You mentioned the difference in treatment when breast cancer is found early versus at a more advanced stage. What do treatment options look like today for early breast cancer? For more advanced breast cancer?

iStock_000020255467XSmallDr. Grumley: I have a perfect example of a patient I treated. Her annual mammogram revealed a small tumor. Because the tumor was just a few millimeters, the patient could have a partial mastectomy, with breast reshaping using oncoplastic surgery techniques, plus one dose of radiation administered during surgery. She was done with her main treatment in one day. Had we waited another year, the tumor would likely be larger and require more extensive treatment, such as weeks of chemotherapy and radiation therapy. One day of treatment compared to months, with more toxicity and side effects.

We have to help women understand the screening process, how it’s important not just for survival, but also because if we get it early, we don’t have to do as much to treat you. Women often think breast cancer means mastectomy and chemotherapy, but early detection means we are doing far fewer of both. There have been great advances, including drug therapies that treat by cancer type, breast preserving lumpectomies and the possibility of intraoperative radiation therapy for localized tumors. Today there is good reason to be less fearful of what can be a very treatable cancer.

Educating women about the benefits of regular breast cancer screening could greatly affect decisions they make about their own health. How do you help more women get this information?  

Dr. Grumley:  I meet with primary care physicians and say it’s not about telling your patients what they should do, it’s about providing education. Explain what mammograms really tell us, what a callback means, what a biopsy means, and the patient can decide for themselves. Talk about how treatment plans change depending on when cancer is found. It only takes one good conversation. And if the provider wants more support for that conversation, they can have their patient follow up with a breast specialist. Because when it comes to screening decisions for breast cancer, receiving complete information is the best anti-anxiety medicine there is.

Knitters Show Their Support for Worried Mammography Patients

… because a little piece of yourself goes into everything you knit …

~ McCall’s Knitting Slogan, 1955

During Breast Cancer Awareness Month, it is easy to put on a pink ribbon to show your support. At Virginia Mason Federal Way, the team not only puts on their pink ribbons – they take out their knitting needles and get crafty to show support to patients who are called back after a screening mammogram.

A mammogram is a low-dose X-ray exam of the breasts to look for changes that are not normal. The results are examined by a radiologist, who looks for changes in breast tissue that cannot be felt during a breast exam. It’s the most effective way to find breast cancer early. Like with any screening test, going in for a mammogram can cause some worry about what the radiologist may or may not find. Receiving a callback for more testing (such as a diagnostic mammogram, ultrasound or biopsy) can heighten this anxiety with the thought of possibly having breast cancer.

The Federal Way mammography team understands getting a callback can be a trying time for patients and three years ago started doing something special during Breast Cancer Awareness Month to show they truly cared. Judy Gross, radiology lead, coordinated the creation of handcrafted pink washcloths knitted by team members to give out to concerned callback patients.

“The team understands this is a difficult time for these patients,” said Vicki Wiitala, Federal Way Radiology’s clinic manager. “We want to do something special for them to show we care.”

2013 Knitters

This year’s team of knitters included Virginia Mason Federal Way mammographers Dolores Range, Kathy Druzianich, Judy Gross, Jeanette Mishler and JoAnne Molinari (all pictured), plus Naomi France, RN; Teresa Fox, RN; and many family and friends.

And while knitting a pink washcloth seems like a simple gesture, it takes a village of volunteers to knit the amount needed for the month of October. The Federal Way clinic usually sees 15 to 20 patients per week who are required to come back for a diagnostic mammogram or additional views. The team needed to knit more than 100 pieces to give out during October. And all the knitting is done on the team’s own time – at home and during breaks. Besides the joy of knitting, why do they put in all this effort? Several of the team members have a family history of breast cancer, so they recognize the importance of raising awareness about having a screening mammogram.

“The goal of a mammogram is to find cancer when it is small,” explains Peter Eby, MD, who is the section head for breast imaging at Virginia Mason. “We recommend screening mammograms once a year starting at age 40. The odds of getting breast cancer at that young age are low, but finding it early gives women the best chance of beating it.”

Although the pink washcloths help raise awareness, it’s really more about comforting patients. “We felt giving out the washcloths brightened a patient’s day when they are going through a stressful and scary time,” explained Vicki.

It is not uncommon to be called for a second look after a screening mammogram, and it is important to remember most women do not get breast cancer if they are called back in.

“In fact, 7 out of 8 women don’t get breast cancer,” said Dr. Eby. “And 75 percent of callbacks turn out to be false alarms, but we still need to perform a complete and high quality evaluation. In most cases, we can tell patients there is nothing to worry about before they leave the department.”

In the end, a callback can be stressful, but knowing that most findings on a screening mammogram are not cancer can help ease the worry. And if not, there is always the pink washcloth to let you know you’re in the caring hands of a great team.

To find more information about mammograms and other imaging tests for early detection and diagnosis of breast diseases, visit the Virginia Mason Breast Clinic.