Ask The Expert: Breast Cancer Screening with Susan Harvey

October is Breast Cancer Awareness Month, which has gained widespread attention and support over the last decade. Through all of the fundraising efforts and creative initiatives that have coincided with the campaign, it may be easy to forget a key component to helping fight the disease – getting screened.

Dr. Susan HarveySusan Harvey, director of the Johns Hopkins Breast Imaging section, leads the breast imaging enterprise at Johns Hopkins including the Johns Hopkins imaging sites located at Green Spring Station and White Marsh, the Johns Hopkins Outpatient Center, and the Bayview Medical Center Breast Center. In today’s Ask the Expert, Harvey answers some commonly asked questions about the screening process and explains why getting screened is so vital.

If you have any questions about breast cancer screening, Bonmyong Lee, Assistant Professor of Radiology and Radiological Science will be available throughout the day to answer your questions in the comment section.

What are the current guidelines for getting a screening mammogram?

The guidelines for screening mammography have not changed, but they are inconsistent here in the United States. They vary from beginning annual screening at age 40 without a defined age end point to beginning at age 50 and continuing every other year until age 65. The unfortunate result of the lack of clarity is confusion for both patients and primary care providers. In breast imaging at the Johns Hopkins Department of Radiology and Radiological Science, we follow the American College of Radiology guidelines suggesting annual screening from age 40 onward, which matches several other society recommendations.

What are some of the high-risk factors of breast cancer?

Risk factors for breast cancer can be divided into factors women can change and factors women cannot change.

Factors that cannot be changed include:

Being a woman: Women are 99 times more likely than men to have breast cancer

Aging: The risk of breast cancer increases with age in a linear fashion.

Family and genetics: Only about 10 percent of breast cancers are related to inherited genetic mutations. The most common are BRCA 1 and BRCA2. However, it is important to recall that most cancers arise from spontaneous not inherited mutations.

Breast tissue density

Age of menarche: The age at which women begin their periods is a risk factor. Women are at higher risk when they get their period at a younger age.

Radiation to the chest for malignancy: This is unusual, but treatment of other malignancies with chest radiation elevates the risk of breast cancer.

Previous personal history of breast cancer: This makes breast cancer more likely.

Factors that women can change include:

Weight: Obesity is a breast cancer risk factor

Smoking: This increases lung and breast cancer risk.

Exercise: Women who exercise regularly have a lower cancer risk.

Alcohol intake: Heavy drinking is related to an increase in cancer risk.

Hormone replacement: Long-term hormone use is considered a risk factor.

Child birth: Having no children or being an older age at child bearing is a risk factor.

What can mammogram results tell a woman?

Mammography results can inform women of their breast tissue density and also about vascular calcifications, which in some instances can be reflective of other vascular disease. There is compelling evidence that breast density is a risk factor for breast cancer, either on its own or in combination with other risk factors. A higher breast density may signal the need for supplemental screening examinations, such as a breast ultrasound or breast magnetic resonance imaging.

Can those results indicate other issues?

There are other findings on mammography that can be clues to or are signs of disease. For example, enlarged lymph nodes can be a sign of lymphoma, autoimmune diseases, inflammation or infection. There are times when edema, or swelling, in the skin, can be seen with cardiac dysfunction or infection. Calcifications in lymph nodes can be seen with previous fungal infections and sometimes with previous radiation treatment.

Are there any new technologies being applied to the breast screening process?

Three-dimensional mammography is a new technology that is an advanced digital mammogram. This technique allows several low-dose images to be reconstructed into 1 millimeter slices through the breast. This is similar to computed tomography, or CT, used in other parts of the body. Three-dimensional mammography mitigates the impact of overlap and summation of tissues, which can both obscure and mimic cancers. This allows an increase in invasive cancer detection and a decrease in the number of women recalled for further evaluation. Three-dimensional mammography is a more accurate screening test, as shown by several large trials in the U.S. and Europe.

What does it mean when someone is called back for additional imaging?

Being called back means that a possible abnormality has been seen on screening mammography and requires further evaluation to assess if there is a significant finding that could be suggestive of breast cancer. The majority of women asked to return are found to have normal breast imaging or a benign, non-cancerous, finding at the time of further evaluation. Only about 2 percent of women require biopsy after this further imaging is performed.

What is the difference between a screening mammogram and a diagnostic mammogram?

Screening mammography is a four-view imaging exam performed in women who have no clinical symptoms or signs of cancer. This exam has been proven to decrease mortality from breast cancer from 30 to 40 percent.

Diagnostic mammography is performed for women who have symptoms such as a palpable lump or nipple discharge. In addition, diagnostic mammography is performed for women who have had breast cancer treated in the past or who have been identified to have an abnormality on their screening mammogram that requires further evaluation. Breast pain can be an indication for diagnostic mammography but only when previously assessed by a woman’s primary care provider.

What can women do to help avoid breast cancer or detect breast cancer early?

Annual screening mammography was proven to decrease mortality by 20 to 40 percent in large European and American trials. Annual screening mammography is one of the most significant actions women can take to allow earlier detection of breast cancer.

As mentioned above, there are also some behaviors and life style choices that can impact breast cancer risk.


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{ 2 comments… read them below or add one }


Ashlyn Jones October 7, 2014 at 11:31 am

I am 24 years old and my mother was 22 when she was diagnosed with her first breast cancer and 36 when diagnosed with a second breast cancer ( not a reoccurrence ). Then at age 42, because of heavy bleeding, she had a hysterectomy that resulted in a diagnosis of uterine cancer. My question is should, I be getting routine mammograms. I had one at age 18 and one at age 22, but its always a fight with the insurance company and I usually give up. The breast center that I went to suggests I get screened every 6 months alternating mammograms and MRI.
If I should in fact be screened routinely, how can I without going through the hassle with my insurance carrier ( JHH EHP ). Any Suggestions will be greatly appreciated.


Will Cox October 7, 2014 at 4:40 pm

Hello Ashlyn,

Thank you for your questions. We will work to get a response for you and hope to have one very soon.


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