Everyday Health: What are your thoughts about the task force recommendations? Do they go far enough?
Ryland J. Gore: In the oncology world, we’ve been extremely frustrated with the task force recommendations for years. For many years, they’ve recommended women start getting mammograms at age 50 and continue getting mammograms every other year.
The USPSTF continued to double down on this recommendation even though other organizations, such as the American College of Radiology (ACR), American College of Obstetrics and Gynecology, the American Society of Breast Surgeons, and the National Comprehensive Cancer Network have said to start at age 40 and get one every single year.
And this is for women of average risk — obviously, if you have risk factors, genetic mutations, other extenuating circumstances, you may need to start earlier than 40. People have been getting bad information about breast cancer screening for a very long time. It’s extremely disappointing.
I am happy that the USPSTF finally realized that we should start earlier, especially for these groups of women — but it’s not enough. As I mentioned earlier, all these other organizations recommend that women should get mammograms every year.
I’ve seen so many cancers develop in between mammograms, and that’s sometimes in women who were already getting yearly mammograms. I think that by telling women every other year, we’ve missed cancers that could have been diagnosed and treated earlier.
EH: The task force guidelines include information about the increased risk of breast cancer for Black women. Could you talk about that?
RG: The numbers don’t lie. There’s very good data that’s come out from the Centers for Disease Control and Prevention (CDC) and the American Cancer Society in the last few decades that show a disparity between Black women and their counterparts — white or other minorities, for that matter.
We’re 40 percent more likely to die from breast cancer. Our five-year survival across the board, even for stage 1 or stage 2 — early breast cancer is markedly lower than our white counterparts.
Black women are more likely to be diagnosed with the most aggressive form of cancer, triple negative breast cancer. Black women are three times more likely to have this more aggressive form of breast cancer than white women, which is huge.
EH: Considering that increased risk, what factors should a Black woman consider when deciding when to start getting mammograms?
RG: It’s good that the task force is highlighting this increased risk, but this is not a new conversation. In 2018, the American College of Radiology and the Society of Breast Imaging put out a joint statement recognizing that Black women are at high risk for breast cancer and are more likely to be diagnosed before the age of 40.
They recommend that at age 30, Black women start having these discussions about breast health and breast care with their primary care physician or whatever doctor they see regularly to have a risk assessment.
I think it’s fair to say that Black women at this point are not average risk, and so consideration should be given across the board to recommend that they start mammograms before the age of 40. Starting at age 35 should be strongly considered, and they should absolutely be done every single year. I’ve had varying levels of success with getting it covered by insurance, but there are other workarounds.
EH: The task force reported that breast cancer in younger women is on the rise, and that younger women can be at a higher risk of worse breast cancer outcomes. What do younger women need to know about these guidelines?
RG: One of my most memorable patients, I met and diagnosed her with breast cancer when she was 19, and she was a Black woman. I’m happy to report that she’s doing well now, but these are the cases that really break your heart.
It’s one thing for it to happen once or twice, and you think maybe this is a one-off — but it keeps happening, and not just in my practice, but my colleagues across the country are seeing it, too.
I believe in education, education, education. And honestly, as soon as a woman hits puberty, I think we should be having discussions about breast health and breast care. And it’s important for women to have discussions early on about their risk and decide when they need to start getting yearly mammograms.
EH: What if a woman doesn’t have access to her health history, including her breast cancer risk?
RG: There are many patients, you know, where maybe the whole family died when they were young, or maybe they were adopted and don’t have access to their health history.
In those cases, I’m a strong proponent of genetic testing. I think it just gives you a baseline, especially if you know absolutely no health history or you weren’t told your history. Based on those results, we can determine if a woman might be at higher risk or average risk.
EH: What should you do if you find a lump or symptoms that could be consistent with breast cancer before age 40? Or before the age your doctor suggested that you begin getting mammograms? Should you push to get one?
RG: If you have a lump, or just something out of the ordinary going on, but you haven’t reached the age for screening according to your risk, you should definitely tell your doctor what’s going on and ask for a mammogram.
I believe in being a huge advocate for yourself. Ask questions, and if you feel something, say something, even if you’re not 40 yet. Many of my patients are in their thirties or early forties.
And if you don’t feel heard by your provider, it’s okay to get a second opinion. That doesn’t make you a bad person.
EH: Nearly half of all women have dense breasts, which is not only a risk factor for breast cancer, but also can make breast cancer harder to detect in a mammogram. In this draft, the task force concluded that there wasn’t enough evidence to recommend that women with dense breasts get additional testing. What’s your take on that?
RG: I thought it was weird that they didn’t give a recommendation around this. We have several tools in our arsenal that we use, and we use consistently.
For starters, 3D mammograms are becoming much more popular, and they’re starting to be covered more by insurance. Using these cuts down the number of callbacks and decreases the number of biopsies, and I think those are the two things that people worry about.
Also, we have ultrasound, which can be an important tool and is often recommended by radiologists or breast surgeons to women with dense breasts. Ultrasound or any other imaging tool is not a replacement for a mammogram. That needs to be done every year because there are certain things that a mammogram picks up that we won’t see on those other imaging modalities.
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