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Subjectivity Challenges Breast Cancer Exams and Diagnosis Carol Milano, Medical Writer

Mammography is the best tool available for detecting breast cancer. But questions we have no certain answers for may stand in the way of successful detection: How often should the test be given? How old should a woman be when she first has a mammography? How sensitive is a given testing procedure? And how much subjective interpretation is involved in "reading" the results?

x There is consensus that women over 50 should have an annual exam, but experts still disagree over frequency of testing for women between ages 40 and 50. The American Cancer Society and the American College of Radiology have recommended mammography screening for women every 1-2 years beginning at age 40.

But the US National Institutes of Health concluded that there is not enough evidence to recommend yearly mammography for all women in their 40s. Further, in Canada and Europe, a screening mammography is not recommended for women under 50.

Revising its previous recommendation to wait until 50 for annual screenings, the American Medical Association (AMA) said in late June that women age 40 and older should get yearly mammograms. The AMA cited figures saying that 18% of all new breast cancer cases in the United States occur among women in their 40s, and it now encourages the medical profession to come up with a unified recommendation on the matter.

According to the American Medical Association, women age 40 and older should get yearly mammograms.

It's often easy to feel intimidated by a doctor and to become a passive participant in the process. If a doctor doesn't ask about family history, be sure to offer the information--especially if a relative has had breast cancer. If a mass is found, an examination alone cannot determine whether it is benign or cancerous, and you will need to have it tested.

Mammograms can reveal calcifications (which can be markers for cancerous changes) as small as a pencil dot before they become palpable, but the test is far from perfect. Studies by major medical centers find this X-ray 80% accurate, at best. (Mammograms are about 75% accurate in 40-year-old women, but about 90% accurate in women in their 50s and 60s.) No one knows why 10-15% of lumps or lesions simply do not record on X-ray film.

In addition, reading a mammogram can be difficult. A given image may be open to differing interpretation and may be misread. In a recent study at the University of California at San Francisco, two experienced radiologists looking at the same mammograms agreed on what they'd seen less than two-thirds of the time. Keep in mind that no current screening tool is perfect, though an ultrasound combined with a mammogram is about 95% accurate.

Choose your screening center wisely by carefully checking credentials. For a mammography center, make sure it has current Food and Drug Administration (FDA) certification and has been given the nod by either a state accrediting agency or the American College of Radiology (ACR).

"An ultrasound image is only as good as the person who administers it," stresses Marie De Lange, who chairs the American Registry of Diagnostic Medical Sonographers (ARDMS). "To help protect against needless tests, misdiagnosis, or unnecessary surgery to remove a tumor that isn't there, I urge consumers to see a sonographer's credentials before an exam." Says Dr. Henry Ferstenberg, a breast surgeon in New York City, "A doctor should take the time and make the effort to answer all your questions." He adds that requesting a second radiologist's opinion is appropriate and provides additional protection for the patient.

It is also important to provide a new center you visit with copies of mammograms you may have had elsewhere, says Dr. Ferstenberg. "They may not have the old X-rays (for comparison). The percent of error would drop if they did," he says.

Other important circumstances may complicate diagnosis, such as age. False negatives and equivocal mammogram results are most frequent in women under 40. This is because the tissue of the breast is denser than in other age groups, which makes it harder to see what lies within. Unfortunately, breast cancer tends to develop more quickly, once it has begun, in younger women.

During pregnancy, any tumor that may be present will respond to the extra estrogen production. To avoid radiation that could harm the baby, a sonogram can safely be performed on pregnant women.

Your strongest defense against this disease is top-quality screening. These steps may help protect your health:

• Do a self-exam every month at the same time in your menstrual cycle, preferably right after your period has ended, or on the same date if you're menopausal.
• Have an annual mammogram and professional breast exam if you are over 50 years of age and talk to your doctor about the need for mammograms between the ages of 40 and 50. From 20 to 39, it is sufficient to have a clinical breast exam every 3 years.
• Find a certified mammography center (or check the status of your own center) by calling the National Cancer Institute (NCI) at 800-4CANCER.
• If you are going to a new mammography center, get your previous X-rays and bring them with you. They are your property.
• Read your written mammogram report. If it is ambiguous, speak with your physician about whether an ultrasound might be useful. Check your ultrasound provider for ARDMS credentialing.
• If a lump is detected, make sure that you speak with your doctor immediately. Make sure you are comfortable with and understand all recommended courses of action.
• If you need a surgeon, seek someone who has a good deal of experience treating patients with breast disease.

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