Mammogram screening guidelines can be hard to follow, as organizations tend to change them every few years. To keep women up-to-date on best practices, Dr. Ami Chitalia says it's important that doctors reiterate the guidelines and personalize them to patients.
TRANSCRIPT
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thanks for joining us today. We're speaking with Dr. Ami A. Chitalia, a breast medical oncologist at MedStar Washington Hospital Center. Welcome, Dr. Chitalia.
Dr. Ami Chitalia: Thank you for having me.
Host: Today we're discussing the current recommendations for mammography, which is a recommended screening test for breast cancer. The 2018 guidelines from the American Cancer Society suggest that women at average risk for breast cancer have yearly mammograms starting at age 45, and they can switch to every other year at age 55. But, the ACS also notes that women should have a choice to start screening as early as age 40. Dr. Chitalia, with guidelines that seem to change every few years, do you find that women have trouble keeping their screening schedule straight?
Dr. Chitalia: Yes. So, they definitely do have trouble and I don't blame them. I think it's important that physicians reiterate the guidelines to their patients often so that they are aware of any important updates or changes to them.
Host: What's your opinion on when women at average risk for breast cancer should start having annual mammograms?
Dr. Chitalia: So, there are a lot of different answers to this question. Depending on which society's guidelines you follow, such as the USPSTF, which is the United States Preventive Services Task Force, or the ACS, which is the American Cancer Society, and a few others as well. The answers range from starting at age 40 to starting at age 50. Above all, I think it's important to use shared decision making with a physician helping the patient to weigh pros and cons and come to an informed, value-based, individualized decision. That is the model that is recommended by most guidelines, especially between ages 40 and 45. ACS recommends annual screening beginning at age 45 and then, either annually or every other year after age 55. So, shared decision making is again recommended after age 75, as well.
Host: When you have a woman come in, what sort of questions do you ask her or what kind of discussions do you have to help her decide what's best for her?
Dr. Chitalia: Sure. So, that's a great question. So, one of the biggest things is family history, so really getting a good family history of not only breast cancers but maybe also ovarian cancers and other cancers as well. Also, just asking the patient herself if she's ever had any abnormal mammograms in the past, if she's ever had any breast biopsies in the past. That may change your recommendation and make it more specific to her.
Host: What do the 2018 guidelines mean for women at increased risk, such as those with a family history of breast cancer or genetic factors?
Dr. Chitalia: So, if a woman carries a family history of breast cancer, that may mean she is recommended to undergo screening at an earlier age than an average woman. An example of genetic factors may be a BRCA 1 or 2 mutation, which are the most common mutations associated with hereditary breast cancers. So, for the majority of these women, the recommendation is to have their first screening mammogram at the age of 30.
Host: Do women need to do anything special to prepare for a mammogram?
Dr. Chitalia: So, it's suggested that women schedule their mammogram at the time when their breasts are the least tender, which usually tends to be the week after their menstrual cycle, but this can be somewhat different for each woman. If they've had mammograms at another facility is the past, it's usually a good idea to bring those images and reports in with them so that the radiologist reading their current mammogram can use them as a comparison. They should also let the technician know if they have had previous biopsies or if they have breast implants. And also, it's recommended that deodorants, perfumes, and lotions be avoided under the arms or on the breast area during the morning of the mammogram.
Host: Could you describe what a woman should expect at her mammography visit?
Dr. Chitalia: Sure. So, she'll be asked to remove clothing from the waist up as well as a necklace, if she's wearing one. She will be standing, and she'll be asked to place each breast, one at a time, on a platform on the machine and the technician will help to place her arms and head so that they don't block the breast and so that they can take the best images possible. The machine will then compress the breast in order to take pictures. So, the reason that that's done, it's important for breast tissue to be spread out, as much as possible, so that the x-ray can go through all of the tissue and the most complete and detailed set of pictures can be taken. The whole process should take no more than 20 to 30 minutes. So, I know a lot of women do have some anxiety related to their mammogram - fear of sort of discomfort or pain, and so, you know, I always tell patients that it is okay to take a mild pain medication, such as Tylenol or an Ibuprofen product, as long as it's approved by their physician, maybe an hour before the mammogram to alleviate some of that discomfort, if they've experienced that before.
Host: What sort of questions do women ask about getting their mammogram?
Dr. Chitalia: So, typically, by the time they've come to see me, they've already had their mammogram so, of course, they are somewhat anxious to hear their results, especially if they've had some abnormality in the past. It depends on what type of mammogram is ordered. There are screening mammograms and there are diagnostic mammograms. The screening mammograms - they do not get results right away. It usually takes about a week or so, depending on the institution. So, for those, I think they tend to be a little bit more nervous because, if all is normal, usually it's a letter in the mail and, if not, they get a phone call to come back. For the diagnostic ones, they're actually told of their results there and then, that same day, before they leave from their mammogram. So, I think for those, they've already been told and that's ok. And a lot of my patients are getting diagnostic mammograms since they're coming to me, usually for some sort of a breast abnormality.
Host: So, the guidelines that we've been talking about are regarding screening mammograms where you're getting checked for a potential breast cancer. What happens if something is found that's perhaps abnormal during that screening mammogram?
Dr. Chitalia: So, it depends on the abnormality. And, that can range from repeating the mammogram in 6 months, which is earlier than the usual annual repeat. It could also mean getting additional views, so if it's a screening mammogram that caught something that needs additional views, that should be done right away, within, you know, days to a couple of weeks. And THAT would be a diagnostic mammogram. In addition, usually a targeted ultrasound to that region is done. Sometimes, depending on the woman and her history, it could mean an MRI of the breast. So, it sort of depends on what the abnormality is. If it's clear that it's a benign abnormality, such as a cyst seen on the ultrasound, then usually that's just followed in a bi-annual or annual basis. And sometimes, depending on the woman, they can have a biopsy if it's something benign like a fibroadenoma and usually that's it and then they resume their usual screening. So, the answer is it really depends on the abnormality that is found, the grade or the score that it's given by the radiologist, and then the recommendation that's given following that.
Host: Why is MedStar Washington Hospital Center the best place for women to seek breast cancer screening?
Dr. Chitalia: MedStar Washington Hospital Center does a great job in a lot of different areas, you know, so we do offer state-of-the-art equipment and imaging techniques, including MRI guided biopsies, which are only actually offered at certain selected imaging centers. And we do offer comprehensive care so if there is an abnormality, they can see a large multidisciplinary team, including nurses, radiologists, surgeons, radiation doctors and medical oncologists, such as myself, all, you know, in the same building, which is nice for them. We also have dedicated breast radiologists who have sort of expertise in reading mammograms. And, you know, I think also our nurses, our technicians, the staff are really kind and caring and just kind of aim to make sure that their experience is smooth and comfortable. So, I really feel that MedStar Washington Hospital Center is a great place to go for a woman to have their mammogram.
Host: Could you share a screening success story from your practice?
Dr. Chitalia: So, I've had a few patients recently who were found to have a pre-invasive cancer, which is sort of a pre-cancer before it takes its next step to becoming a true invasive breast cancer. This was actually found on their very first screening mammogram in their forties. So, both patients felt lucky to find it at this stage where it was actually a stage 0 cancer and the treatments, at that point, are much easier to take.
Host: If you could summarize the screening guidelines and how those are followed at MedStar Washington Hospital Center, what would you recommend to a woman at average risk for breast cancer about the importance of getting her mammograms every year?
Dr. Chitalia: Yeah, so, I think, you know, once we've had the discussion and they've reviewed their medical history, their family history, any personal breast history with their primary care physicians and a decision has been made to proceed with mammogram, I think it's important that they do so because if an abnormality is caught, it can be treated promptly and followed promptly. So, I think that sticking to, you know, that annual screening is important because it can catch something early and it can be taken care of in an expedited manner.
Host: Thanks for joining us today, Dr. Chitalia.
Dr. Chitalia: Sure! Thanks again for having me.
Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.
