Mammograms have been in the news lately, and it can sometimes be a bit confusing. But the guidance from Mount Sinai doctors remains unchanged and simple: You should start getting mammograms at age 40 and continue yearly.
In this Q&A, Elisa Port, MD, FACS, Chief of Breast Surgery and Co-Director of the Dubin Breast Center, explains why changing guidelines from groups such as the U.S. Preventive Services Task Force have not altered the recommendations of doctors like herself to urge women to start mammograms at age 40 and have them every year. She also explains why this longstanding recommendation for annual mammograms starting at age 40, based on extensive data, is critical for Black women, who are more susceptible to an aggressive form of breast cancer, and why new regulations from the Food and Drug Administration on breast density are also important.
Elisa Port, MD, FACS
What is the latest advice on the age that people should start getting regular mammograms?
The age that women should start getting mammograms has never changed from the perspective of health care professionals. There is tons of data and research that has shown that starting at age 40 and yearly thereafter is the best way to detect breast cancer early and gives women of all those age groups the best chance of survival if they do develop breast cancer that is found through early detection. What has not been consistent is that, starting in 2009, and then again in 2016, a number of groups, such as the American Cancer Society and the U.S. Preventive Services Task Force, started putting out guidelines that differed from that. These were basically prioritizing different factors, and taking into account such things as the anxiety of patients, false positives, and cost. But doctors have known all along that the optimal way to screen women for breast cancer, with the highest chance of survival, is starting at age 40 and continuing yearly thereafter.
What is the U.S. Preventive Services Task Force?
The task force is an independent, volunteer panel of experts on prevention and evidence-based medicine that provides guidance to primary care physicians about preventive services such as screenings and counseling services. It is one of several leading sources of guidance to physicians.
What are the reasons for the new guidance from the task force to start mammograms at age 40?
One of the reasons for the change in its guidance on mammograms was newer data, very disturbing, showing that Black women—who we know can develop cancers younger—are more at risk for developing a particularly aggressive kind of cancer called triple negative breast cancer that can grow more rapidly. The death rate in Black women who get breast cancer is substantively and unacceptably higher. So this change in recommendation is a limited response to that data, saying one thing we can do to address that is revert back to starting screening at a younger age. But they did not go far enough.
How is the risk for Black women different?
One of the biggest issues specific to Black women is that breast cancer is not just one disease. Breast cancer involves multiple different subtypes. Each of these different subtypes is treated differently, has a different pathway, and behaves differently. One of these subtypes, called triple negative breast cancer, is the most aggressive kind of breast cancer and also one of the most difficult to treat. We know that of all breast cancers, triple negative makes up only about 15 percent. However, there are certain groups that have a higher chance of developing triple negative breast cancer and are at high risk for developing that subtype. Black women are one of those groups. When they develop breast cancer, there is a 30 percent chance it will be triple negative, not 15 percent. So it is much higher. As a result, they may need to be screened earlier, and with greater frequency.
Should people be concerned if they cannot afford a mammogram?
At Mount Sinai, we feel very strongly that women should keep to our guidelines, and we accept all insurance. We will do everything within our power to make sure that all women, even those without insurance, regardless of their ability to pay, get the care they need.
Are there any exceptions for the guidance that mammograms should start at age 40?
One of the things that we have made so much progress on, and that I’m so proud of, is there is not a one-size-fits-all approach. There are groups where we might even start screening earlier. Women with a family history of breast cancer, particularly at a young age, may start screening earlier and add other adjunctive tests like ultrasound or MRI—these are all considered in our high-risk populations. For example, if your mother was diagnosed with breast cancer at age 45, we typically advise starting screening about 10 years younger than the youngest family member diagnosed with breast cancer. Doctors might recommend starting at age 35, and recommend that you seek personalized advice and guidance regarding screening.
The FDA recently updated its regulations to require mammography facilities to notify patients about the density of their breasts. What does this mean for patients?
The density notification is a very important step because it tells women and their providers if they might be at higher risk for having a cancer missed, and potentially should be adding screening tests, like ultrasound and MRI, to close the gap in case mammograms are missing something. What is most important is that knowledge is power—women should be empowered to know more about their bodies. It does not automatically mean everyone needs an ultrasound or an MRI. It is a very nuanced discussion with one’s doctor, but it is a data point that can factor heavily into making these decisions. Breast density can only be determined one way, and that is based on a mammogram. We cannot tell breast density from the physical exam, or age, or family history. Based on that mammogram, one can then have an educated conversation regarding whether any additional imaging is appropriate
Will this new regulation produce any changes for Mount Sinai patients?
Many states, including New York, already had laws regarding breast density notification before the FDA’s action. So here at Mount Sinai, patients are already learning about their breast density, without the new FDA notification. Now all states, including New York, will need to do this in a uniform way. So there may be some small change for us in the notification language we send to patients.
What should I do if I have any questions or concerns about mammograms?
Primary care providers and gynecologist are the ones who order most of these tests. Their role is to customize and personalize any kind of cancer screening based on the individual, her family history, age, and other medical issues. That is what a good doctor does: takes all these considerations and puts it all together in a thoughtful approach for the individual.