Women's health screening guidelines have changed a lot over the past decades. For many of us, cervical cancer (pap) screening has become less frequent. At the same time, breast cancer screening recommendations have changed, from the old routine of a breast exam every year and yearly mammograms starting at age 40, to the newer recommendations for mammograms starting between the age of 40 and 50, done every 1-2 years, and possibly less frequent breast exams as well.
The new approach at first glance seems to do less for patients. Less breast exams? Later mammograms? Why would we want this? Doesn't cancer screening find cancer early and decrease cancer deaths? Yes, early cancer detection can save lives. But no healthcare is without risks or downsides, and most healthcare decisions are about weighing the possibility of improving our health with the risk of problems or side effects that are unwanted. This article will cover risks and benefits as well as professional recommendations so that you can make a plan with your provider for your breast cancer screening.
In healthcare, screening tests are tests that are done on people who don't have signs or symptoms of an illness. Screening tests are for large groups of people with average risk to find those who have a serious problem. Finding the problem might allow us to treat it before it gets worse or before it causes other problems. Screening is not the same as diagnosing. Someone with a breast lump or other breast concern already has a problem, so they need a diagnosis of the problem, not screening.
A quick note: Please do not rely on this article alone to make your health care decisions: the best course is making a breast cancer screening plan with a provider you trust. If you have a current breast concern you should make an appointment with your provider right away!
Benefits and Risks
Benefits of breast cancer screening:
The main benefit of breast cancer screening (both mammograms and breast exams) is that they can find breast cancer, as early as possible. Finding cancer early increases the chance that we can treat the cancer before it becomes fatal, potentially prolonging the patient's life.
In patients over 50, there is clear evidence that screening mammograms decrease breast cancer deaths. In patients under 50, the evidence for this benefit is not as clear, but certainly some individuals younger than 50 will develop breast cancer, and mammograms can help find those cancers earlier.
A provider performed breast exam may find a cancerous breast lump, but research to date has not been able to prove that breast exams decrease breast cancer deaths.
Patients may feel reassured and relieved after breast cancer screening.
Risks specific to mammograms
Some patients find mammograms uncomfortable or inconvenient.
Mammograms expose you to a very small amount of radiation each time you have one. (However, patients are much more likely to find a cancer with a lifetime of mammograms than to have a cancer caused by a lifetime of mammograms. )
Mammograms may miss some cancers, or only find a cancer that is already so advanced that it will be fatal.
Mammograms may give an abnormal result even when there is no cancer (a "false-positive"). More tests will be needed to see if there is cancer or not, which can be costly or uncomfortable and have side effects of their own. Waiting for these test results can be very stressful for patients. Screening starting in the 40's increase the chance of needing additional tests that turn out to be normal.
Mammograms may find a cancer that was never going to become fatal, but will require treatment as we do not have a way to tell which cancers do and don't progress.
Risks specific to breast exams
Breast exams may miss cancer, or only find a cancer that is already so advanced it will be fatal. Even with widespread breast exams, it's still mostly patients who find their own cancerous breast lumps.
Breast exams may find breast lumps that are not cancerous (a "false-positive"). More tests will be needed to see if there is cancer or not. These can be costly or uncomfortable or have side effects of their own. Waiting for these test results can be stressful for patients.
Some patients find breast exams uncomfortable.
So with all these things to take into consideration, what do the experts think? Many major organizations make recommendations about breast cancer screening in the US. The most well known are The American Cancer Society (ACS), The US Preventative Services Task Force (USPSTF), and The American College of Obstetricians and Gynecologists (ACOG). These organizations make recommendations about when to start and stop screening, what screening to do, and how frequently to do the screening.
WHEN to start mammograms?
ACS: Optional from age 40-44, then start at age 45
USPSTF: Optional from age 40-49, then start at age 50
ACOG: Start at age 40
General consensus: Anytime after 40, but definitely by age 50.
My thoughts: Women in their late 40s are more likely to develop breast cancer than women in their early 40s. Starting mammograms at age 45 for average risk women is a solid middle-of-the-road approach, but starting earlier or later is completely reasonable also.
HOW OFTEN to do mammograms?
The organizations also make recommendations about the frequency of mammograms, as doing mammograms too frequently might have the same downsides as doing them too early.
ACS: once screening has started, continue yearly until age 55, then every 1-2 years after 55
USPSTF: every two years
ACOG: every 1-2 years
General consensus: 1-2 years is acceptable
My thoughts: Aim for yearly and if you're a little late you're still in the recommended range!
What about BREAST EXAMS? (for women without symptoms)
ACS: not recommended for average risk women, regardless of age
ACOG: for ages 25-39, a breast exam every 1-3 years; for ages 40+, a breast exam yearly.
General consensus: optional starting at age 25, consider an interval of every 1-3 years
My thoughts: If you like having reassurance that your breasts are normal, have a breast exam. If you don't need the reassurance you can safely skip it.
When does breast cancer SCREENING END?
ACS: stop anytime after age 75 if there is less than 10 year life expectancy
ACOG: optional to stop screening at age 75
The USPSTF did not make a recommendation.
General consensus: consider whether to continue at age 75
My thoughts: this is an individualized discussion and your preferences are the most important factor.
Your Breast Cancer Screening plan
The good news here is that the variety of expert opinion means patients can reasonably choose the kind of health care that fits them, instead of a one-size-fits-all approach. I recommend you talk to your provider about whether you would like a breast exam and/or mammogram to screen for breast cancer, and hear what their recommendations are. Together, you can make a plan and stick to it. Keep these things in mind when you do:
Your wishes matter. Your provider should check in with you at your wellness visits about whether you are ready to start mammograms and whether you would like a breast exam.
Recommendations for the general population don't take into account your own particular risk factors. Your personal and family history may lead us to recommend earlier breast cancer screenings (for some patients, we might even start mammograms before age 40). Your provider can talk about your personal and family risks for breast cancer, which may influence your screening decisions.
Your awareness of your body is important. Talk to your provider right away if you notice changes in the breasts or find a lump.
For those who want more information before talking to their provider, consider this tool:
When should I start having mammograms? (Kaiser)
For a summary of breast cancer screening guidelines see: