Breast cancer screening and risk assessment

Breast screening is a system rather than a single test. It combines an honest assessment of your personal and family risk, a decision about when imaging should begin and how often to repeat it, attention to breast density, and a clear plan for what happens if something is found. We carry out the risk assessment, the clinical examination and the follow up at Elite Gynecology, and refer you to dedicated breast imaging centers for mammography, ultrasound or MRI. The reasoning behind each of those steps is set out below.

What screening can and cannot do

Screening mammography reduces deaths from breast cancer. The benefit is largest in women in their fifties and sixties, present but smaller in the forties, and increasingly dependent on general health from the mid seventies. That is the honest shape of the evidence. The costs are real too: false positives that lead to extra imaging and sometimes biopsy, a small radiation dose, and overdiagnosis, meaning the detection and treatment of cancers that would never have caused harm in that woman's lifetime. Nobody can tell you in advance which of those categories your own result will fall into, which is why when to start and how often to screen is a considered decision rather than an automatic one.

None of this is an argument against screening. It is an argument for understanding what you are agreeing to, so that a callback for additional views is read as the common and usually benign event it is, rather than as a crisis.

The clinical breast examination

A clinical breast examination covers both breasts, the axillae and the areas above the collarbone, looking for a discrete mass, skin or nipple change, or asymmetry that is new. Its value as a screening test in women without symptoms is not well supported by trial evidence. Some bodies recommend against it for average risk women, others say it may be offered, and the Task Force considers the evidence insufficient. We offer it and generally perform it, for two reasons: it is the moment at which many women raise a change they had noticed and not reported, and in the years before imaging begins it is the only breast assessment available.

Formal monthly self examination on a fixed schedule is no longer recommended as a screening strategy. Breast self awareness is: knowing what your breasts normally feel like and reporting a new lump, persistent focal pain, skin dimpling, nipple retraction or spontaneous discharge from a single duct, particularly if it is bloody. A new discrete lump is evaluated with targeted imaging whatever your age and whenever your last mammogram was.

When mammography should start, and how often

This is where the major guideline bodies genuinely disagree, and any page presenting a single number as settled is misleading you. The current positions, in outline.

• US Preventive Services Task Force: screening every 2 years from age 40 through 74
• American Cancer Society: option to begin annually at 40, annual screening from 45, then every 1 to 2 years from 55 while life expectancy is at least 10 years
• American College of Obstetricians and Gynecologists: offer from 40, begin by 50 at the latest, every 1 to 2 years, by shared decision
• American College of Radiology: annual screening from 40 for average risk women, with formal risk assessment for everyone by age 25

The disagreement is not about the data. Everyone is reading the same trials. It is about how much weight to give a modest additional mortality benefit against the substantially higher rate of false positives and biopsies that annual screening in the forties produces. Annual screening detects more cancers earlier and generates more callbacks; biennial screening produces fewer harms and catches slightly fewer cancers at an early stage. Both are reasonable. We start the conversation at 40, and where your risk is average and you are undecided, screening every two years is a defensible default that you can change at any point.

Digital breast tomosynthesis, often described as 3D mammography, is now standard at most centers. It reduces callbacks and improves detection in denser tissue compared with 2D mammography alone, and it is what we ask for when we refer.

Dense breast tissue

Roughly half of women have dense breast tissue on mammography, and every mammogram report in the United States is now required to tell you which category you fall into. Density matters in two separate ways. Dense tissue appears white on a mammogram and so does a tumor, which means density masks cancers and lowers the sensitivity of the test. Independently of that, high density is itself a modest risk factor for developing breast cancer.

What to do about it is less settled than the notification laws imply. Supplemental ultrasound finds additional cancers, at the cost of a high rate of false positives. Randomized evidence in women with extremely dense tissue supports supplemental MRI for reducing cancers that appear between screening rounds, though whether that translates into fewer deaths has not been shown, and insurance coverage is inconsistent. Contrast enhanced mammography is an emerging alternative. The Task Force has concluded that the evidence on supplemental imaging for density alone is insufficient to recommend for or against it. Our approach is to weigh density alongside your overall risk rather than in isolation: dense tissue in a woman with a strong family history is a different proposition from dense tissue in a woman with none.

Density is a reason to think harder about your imaging plan, not a diagnosis and not an automatic indication for MRI.

Risk assessment and genetic testing

Risk assessment should happen well before imaging begins, ideally in your twenties, because it determines when imaging starts rather than following from it. We take a structured family history covering breast, ovarian, pancreatic and prostate cancer on both your mother's and your father's side, ages at diagnosis, and Ashkenazi Jewish ancestry, alongside your own reproductive history, any prior breast biopsy showing atypia or lobular carcinoma in situ, and any history of chest radiation. Where the picture is not clearly average, we use a validated model to estimate lifetime risk.

A lifetime risk of 20 percent or more places you in the high risk category, where annual MRI in addition to mammography is recommended, usually starting before 40 and pegged to the ages at which relatives were diagnosed. Women who had chest radiation between roughly ages 10 and 30 fall into the same category. Elevated shorter term risk may also make risk reducing medication worth a serious discussion.

Genetic testing is appropriate when the personal or family history meets established criteria: breast cancer diagnosed at 50 or younger, triple negative breast cancer at any age, male breast cancer, ovarian cancer at any age, several affected relatives on the same side of the family, a known pathogenic variant in a relative, or Ashkenazi Jewish ancestry with a relevant history. Testing is now done as a multi gene panel rather than BRCA1 and BRCA2 alone, because genes including PALB2, CHEK2 and ATM carry meaningful risk and change management. Panels also return variants of uncertain significance, which are common, are usually reclassified as benign over time, and should not be acted on. Counseling before and after is part of the process, because a result affects your relatives as well as you.

Imaging, referral and what we do with the result

Elite Gynecology does not perform mammography, ultrasound or MRI on site. We do the risk assessment, the examination, the referral and the interpretation of what comes back, and we send you to breast imaging centers in Manhattan and Queens where the radiologists read breast studies all day and where tomosynthesis, ultrasound, MRI and image guided biopsy sit under one roof. That is a deliberate division of labor rather than a gap in the service.

Every mammogram report carries a BI-RADS category, which is the radiologist's summary of what should happen next. BI-RADS 1 and 2 are normal and benign. BI-RADS 3 means probably benign and prompts short interval follow up, usually at six months. BI-RADS 4 and 5 mean biopsy is indicated. We go through the report with you, arrange the next step and stay involved rather than handing you a phone number. Biopsies are performed at the imaging center, generally under ultrasound or mammographic guidance with local anesthesia, and most come back benign. Because Elite Gynecology is part of a physician owned multi-specialty group, when a finding has implications for contraception, hormone therapy or menopause management, that conversation happens with clinicians who already hold your record.