Q&A: Who should undergo breast cancer screening at an earlier age?

Key takeaways:

• Breast cancer incidence is increasing among younger women.
• Early detection is increasingly crucial for those with a family history.
• Women with dense breast tissue may require additional screening methods.

Breast cancer diagnoses have shown an alarming rise among younger women, highlighting the need for early screening and awareness of risk factors.

Guidelines recommend the initiative of yearly mammograms at age 40 years, but some women with certain risk factors may be candidates for earlier screening, according to a press release.

Healio spoke with M. Michele Blackwood, MD, FACS, director of breast surgery and director of Women’s Oncologic Health at RWJBarnabas Health and Rutgers Cancer Institute, and head of breast surgery at Cooperman Barnabas Medical Center in Livingston, New Jersey, to learn more about who might need to undergo breast cancer screening before age 40 years and what physicians caring for these women need to know.

Healio: Data suggest that breast cancer incidence has been climbing at a steeper rate among younger women. What are the most significant factors that contribute to the increase of breast cancer in younger women?

Blackwood: Cancer diagnosis among women younger than age 40 years has been increasing for more than 10 years. We are seeing younger and younger women with breast cancer, including in their early, mid- and late 20s. This predates COVID and it’s not from the vaccine, which some people have thought about.

We don’t know the cause and effect, but there are certain factors that contribute to risk. Women who have a family history of breast cancer can get breast cancer at a younger age, as can women who have a gene mutation that causes breast cancer.

Lifestyle habits like smoking and drinking alcohol, especially binge drinking, might contribute to the risk. We don’t know if other factors like exposure to hormones, particularly at a younger age, might have an impact, and this is being looked into currently.

The actual “why” is hard to figure out. When we have younger women with breast cancer, we do a deep dive into their background to try and figure it out. Some women were exposed to radiation at young ages, which would also contribute to it. The true cause and effect is not yet known.

Healio: What other lifestyle factors can impact a woman’s risk for early-onset breast cancer?

Blackwood: With certain lifestyle choices, it probably depends on the age of the patient.

For postmenopausal women, having overweight or obesity, or having a sedentary lifestyle, could increase risk for breast cancer and other cancers. Maintaining a healthy weight seems to be a benefit for women and lowers one’s risk for breast cancer.

In addition to smoking and regular alcohol use, people like to blame processed foods, but there’s been no actual true cause and effect with breast cancer. We have to make smart choices in our lives and keep ourselves healthy, and food is the first medicine that goes into us every day. Diets higher in vegetables, fiber and fruit are probably better than eating processed foods. Some people say that less animal protein and fat is beneficial, but that has not been proved.

When you have children or if you have children may impact breast cancer risk. So having children when younger than 30 years seems to decrease risk. That’s something you might not be able to control, but the later you have children, the more that can seem to increase risk for breast cancer. Having children or being pregnant and getting to the point where your body and your breasts have changed and you’re lactating, whether you nurse or not, seems to possibly decrease one’s risk for breast cancer a little bit.

When you get your period and when it stops are other factors you can’t control, but the shorter time frame, meaning you got your period later and it ends earlier, seems to lower risk for breast cancer as well.

Having said this, you can do everything right and maybe still develop cancer or breast cancer. That’s where screening comes in and having access to good health care and doctors who can help the patient cure her breast cancer. We have over 4 million breast cancer survivors in this country right now, men and women. The doctors who treat this routinely are aware of all the latest and greatest treatments, so make sure you get the right care.

Healio: When should women who have a family history of breast cancer begin screening, and what additional measures might be recommended?

Blackwood: We here at RWJBarnabas Health believe that every woman aged 39 years and older should get yearly imaging, meaning a mammogram, possible ultrasound and possible MRI. If women need to be screened at an earlier age, it’s important to understand what family history is. Family history of breast cancer is not your great-grandmother you think had breast cancer. Family history is usually a first-degree relative, so if your mother, father, sister, or one person off from you had breast cancer, then you should start getting screened, particularly 10 years before their age of diagnosis. Recently, I had a patient whose mother had breast cancer at age 42 years, so she needed to start screening for breast cancer 10 years earlier, at age 32 years.

Many younger women may require more than just mammograms because young women often have dense breast tissue because they’re still in the age when they have children. So, sometimes they need an ultrasound.

We also sometimes use MRI with contrast for young women, particularly those who are at high risk, because there are some benefits to it, and it can see through dense breast tissue.

So, women who have a true family history of breast cancer, a sister, mother, father, brother or daughter with breast cancer, should begin their breast cancer screening earlier than the average woman.

Healio: How can women with dense breast tissue increase their chances of early detection?

Blackwood: One way is to know your breast tissue. See if anything is changing in your breast exam. When you shower, do you feel a new lump? Did you ever notice any nipple discharge coming out on your nightgown or your nightshirt? Did you ever see blood coming out of the breast? Is there something different that wasn’t there before? Many women come in with breast pain, but breast pain, thankfully, is very rarely associated with breast cancer, especially when it affects both breasts.

We ask women to be more aware of their breast tissue when they’re showering — we recommend doing it the week after their period — to see if they feel anything new. If there are any changes in their breasts, bring it to their gynecologist’s attention, and the gynecologist can order an ultrasound, mammogram, or sometimes a biopsy. This way, you don’t have to worry or think about it all the time.

Healio: What are the advantages and limitations of using MRI or ultrasound as complementary screening tools alongside mammograms?

Blackwood: MRI is very different than ultrasound. MRI is a very comprehensive test, meaning that it looks at both breasts at the same time. It can see through dense breast tissue. It can see how the breast tissue is functioning, meaning that if a piece of breast tissue may not look right, or if it’s cancer, it will look different on the MRI. It can find new tumors in the breast. It can find breast tissue that is behaving abnormally. It can look at your lymph nodes to see if they’re swollen. It can look from shoulders to liver, considering any changes in both anatomy and physiology or how the breast tissue is functioning.

Ultrasound is a more common tool. It can look at breast tissue and tell us whether something is a cyst or it’s solid. The issues with the limitations of ultrasound are, that it’s hard to get the whole breast scanned and it must be done with a good technician and a good machine. Sometimes, even with dense breast tissue, it doesn’t help much. It can add about 3% to our knowledge of what’s in the mammogram, whereas MRIs can add 30% to our knowledge. So, true screening for true high-risk patients should include an MRI, not just an ultrasound with the mammogram.

Healio: What are the potential benefits and drawbacks of starting breast cancer screening at a younger age?

Blackwood: The drawbacks of starting breast cancer screening at a younger age are that sometimes even with the best breast cancer screening tools, you might not see something with very dense breast tissue. Other things could lead to some biopsies with a needle at a younger age because the radiologists might not be able to determine whether it’s cancerous, whether it’s new or whether it’s a solid lesion. The benefit of knowing something early outweighs the drawbacks.

The benefit, of course, of breast cancer screening earlier is that we can find breast cancers at an earlier age at a smaller size and a more treatable stage.

Mammograms involve a small dose of radiation. If I have a patient younger than 25 years, many times, I’d rather do an ultrasound and or an MRI than a mammogram because we try to limit their amount of total radiation for the whole body. It’s important that doctors keep this in mind when they start putting patients into any test that has possible long-term side effects.

Healio: What are the most important steps women can take to advocate for their own breast health and ensure they receive appropriate screening and care?

Blackwood: I think it’s also important to look honestly at your life. Did your mother or sister have breast cancer? Did you have a biopsy in the past? Did you or do you smoke? Do you drink? Are you overweight? Do you have a sedentary lifestyle? Did you not have kids? Did you never get pregnant? All of these things can go into whether you’re higher risk, and if you are, you need to think about making sure you talk to your doctor at your yearly exam about where you fall into this risk assessment.

One of the most important things to do if you’re under age 40 years is to access one of the risk calculators online, such as the IBIS or Tyrer-Cuzick, as well as the Gail Model that’s available for women aged 35 years and older.

If your risk on any of those risk assessments is 20% or greater in your lifetime, that means you’re at higher risk for breast cancer. The average risk for American women in their lifetime to age 90 years is 12%. Having said that, that doesn’t mean at age 20, 30 or 40 years you’ll get breast cancer, but that is the risk for your entire lifespan. If you do have a lifetime risk for breast cancer that’s 20% or greater, you need to be seen by trained professionals who can oversee your management — make sure you go to a good breast center with imaging, breast surgeons, nurse practitioners or physician assistants who can guide you through appropriate screening and talk to you about the prevention of breast cancer, because there are ways to prevent breast cancer or reduce your risk. One of those is tamoxifen, which can lower the risk for developing estrogen receptor-positive breast cancers. Also, some people who are very high risk for breast cancer think about having surgeries where you take the breast tissue out of the envelope of the skin and recreate a new breast. So overall, there are things one can do to reduce your risk if you’re very high risk, there are things you can do to mitigate that risk. And, you can screen earlier for breast cancer if you’re high risk. It’s important that you talk to your doctor about where you fit into that timeline.

Healio: Many women may feel anxious or scared about the possibility of needing breast cancer screening before age 40 years. How can health care professionals address these concerns and help patients feel more comfortable about the process?

Blackwood: I think it’s important if a patient doesn’t understand what it means to be at risk for breast cancer, the yearly exam is a great time to have that conversation. I always tell patients to write down their concerns if they have them so they don’t forget them while at their appointment. Make sure that those questions are addressed by your doctors at these exams because that’s your opportunity to have those concerns addressed in a timely fashion with good information.

Reference:

• Am I too young for a mammogram? https://www.cinj.org/am-i-too-young-mammogram. Published Oct. 1, 2024. Accessed Nov. 14, 2024.