The 20-Year Mammogram

I have a close female friend who is highly educated on the graduate level, but she was born and raised in the agricultural Midwest where preventative medicine is not a common meme.  Her last mammogram was 20 years ago.  She shared the story of her latest breast exam with me so that I might share it with you now.  There are three reasons why she waited so long between mammogram.  One, they hurt too much.  Second, there’s been some research suggesting regular mammograms may not be helpful.  Finally, they hurt way too much to get every year!

I can try to understand the mammogram pain — especially in the bilateral views where they not only squeeze your breast downward between two plates, they then squeeze it sideways between two plates, too.  We men nod our heads as we try to understand that sort of squeezing pain, but I’ve never met a woman who enjoys the discomfort of the mammography radiology process.

The modern science concerning the necessity of mammograms is confusing:

Upon completion of the first six randomized mammography trials in 1989, the American Cancer Society, the National Cancer Institute (NCI) and various other organizations issued joint recommendations for women aged 40–75 years. Subsequent analysis, however, demonstrated negligible benefit in the 40- to 49-year-old subgroup. This was in striking contrast to patients 50 years and older, for whom an overall 25–30% reduction in breast cancer mortality was observed. In 1992, Canadian investigators reported no significant benefit for mammography in women aged 50–59 years and a statistically insignificant excess of breast cancer mortality in the mammography group in women aged 40–49 years.

In America, mammograms are plummeting in popularity:

According to these researchers, there has been a decline in the number of women 40 to 49 getting mammograms. That means patients are listening and making decisions based on their individual health characteristics and risk factors.  This is what you want people to do when the science gives them choices.

My friend’s GYN was horrified to learn it had been 20 years since her last mammogram and pap smear, “Back when you didn’t need them;” and my friend was promptly admonished for not being preventative, “This is New York, not the Midwest.  We go to the doctor here.”

The fact that my friend has breast cancer in her family history didn’t help assuage her doctor’s concerns and a pap smear and a mammogram were immediately scheduled because my friend was experiencing pain beneath her right nipple.

When my friend went in for her mammogram, the nurses said they were pretending this was the first mammogram of her life and planned to be very thorough.  They discounted the only mammogram she had 20 years ago.  They bilaterally scanned both breasts and did an intensive ultrasound on her right breast — the whole process lasted 2.5 hours.

Everything, so far, seems fine, but they did find a cyst in her right breast that was likely causing the nipple pain.  Instead of going back in a year or two for her next mammogram, she’s scheduled to go back in six months.  I think the doctors want to track the life of that cyst to see if it shrinks or gets larger.

I don’t know if cysts in breasts are commonplace or not, but I’m sure having a cyst in your breast makes any sort of pressing that breast between two radiological plates a really uncomfortable experience, and it’s too bad there isn’t a less painful way for women to make sure their breasts aren’t killing them.

15 comments

  • Early detection can make the difference between “We safely removed the tumor” and “Dearly beloved, we are gathered here today to remember…” — the pain of the mammogram surely cannot compare to the radical way in which the body is transformed if it survives cancer treatment — I know of people who are still weak in parts of their body that were treated, even years later. This is, of course, if the cancer G-d forbid doesn’t do them in before treatment can succeed. Early detection is crucial!

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  • I was in the UK when I was scheduled for my first ever mammogram at the age of 50. I was called when I was 52. The process was extremely undignified , took place in a “mobile unit” aka trailer hauled around the country. The venue was a supermarket carpark. It was not clean, there was nowhere to disrobe and put on a special gown properly there was no room for anyone to accompany you and nowhere to leave a handbag or any of your belongings safely. The process itself is extremely painful and undignified. Men – think mashed or squeezed testicles and you will get the picture – would you like them strethed out between two sheets of glass and then squeezed …………….. it makes me wince just remembering my mammogram it ranks up there with giving birth and having surgery as one of the most painful experiences in my life.

    David I am very surprised that your friend did not have a biopsy done on the cyst – that would have been the usual proceedure in the UK. It is good they are keeping an eye on the cyst though.

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    • Thank you for sharing the details of your mammogram, Nicola. I’m sorry the experience was so horrible, but I am also glad you went through with it!

      50 is sort of now becoming the “must do it” year for mammograms in the USA — it used to be 20, and then every year after that — unless, of course, you’re having pain, or a family history of breast disease. It seems things happen pretty quickly in the breast and when things start to turn, it happens right away, and waiting even a year between mammograms can be too late. Self-examination is paramount, but even then, half the month a self exam is ineffective.

      I will ask about the biopsy. That’s an interesting thing to check. Her doctor told her if there was anything suspicious in the pap smear or the mammogram that she would get both a call and a letter in a couple of weeks — so, in this case, “no news” really is good news… at least until the next time.

      She’s already complaining about having to go back in six months, and I told her they will likely make her go back every six months for a couple of years until they get a stable baseline on the cyst since they’re treating her as a “never had before” patient.

      I wonder if the intensive ultrasound was a biopsy replacement? It’s certainly less invasive. I didn’t know they did breast ultrasounds, and I’m told they usually do not in a routine mammogram, but her doctor wanted one and the radiology department actually did two ultrasounds on her right breast. They said everything was fine.

      I have no idea how women with breast implants can get a reliable mammogram. You can’t really squeeze a rubber balloon filled with liquid very effectively, and I imagine all that goop would make getting a clear shot of the breast tissue pretty sort of hard.

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  • The ulrasound could have been used instead of a biopsy – however if they were organized beforehand at the same time as the mammogram I would think not and it is just part of the “catch up on 20 years of missed mammograms” plan.

    Your question about implants is adressed here – http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Breast_implants_and_mamagrams

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    • I know in the USA that doctors are trying to be less invasive with needles and knives and are now relying more on imaging to tell them what’s up because it’s safer and doesn’t cost as much insurance money to cut or pierce — that said, last semester, I had a student who had a breast biopsy with a large needle and she actually came to class after the procedure. She told me because she wanted me to know why she was unable to raise her right arm.

      The implant URL is not loading for me!

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      • working here – note it is an Australian site hence the mention of Victoria

        I will quote

        “Breast screening mammograms (breast x-rays) are generally safe for women with breast implants. However, there may be risks. The mammogram might also be less effective in detecting cancer for women with implants because the implant affects how much breast tissue can be seen.

        It is important to tell the breast screening clinic if you have implants, as different techniques may be used for the screening mammogram.

        Breast implants

        Breast implants (also called breast prostheses) are inserted to enlarge or change the shape of the breasts or to reconstruct the breast following surgery. A breast implant has a shell or envelope made of silicone. The shell is filled with either silicone gel or a saline (salt) fluid or a combination of both.

        Breast screening

        Women aged 50 to 69 are invited to have a free breast screening mammogram every two years through the BreastScreen Australia program. Having regular screening mammograms (breast x-rays) is the best way to detect breast cancer in its earliest stages.

        Breast screening can find most breast cancers present at the time of the mammogram but, like many medical tests, it is not 100 per cent effective. The presence, type and position of the implant within the breast affects how much breast tissue can be seen on the mammogram.

        If you have implants because of treatment for breast cancer, a general breast screening service such as BreastScreen is not the best service for your needs. You should discuss your individual circumstances with your doctor.

        Implants and cancer – no evidence

        Currently, there is no evidence that breast cancer occurs more often in women who have breast implants than in women without breast implants.

        Different screening mammogram procedures

        It’s important for BreastScreen to know if you have implants. The radiographer who takes your mammogram may use special techniques to achieve clear images of your breasts. You might find this uncomfortable.

        Some women may feel concerned about being exposed to radiation. Breast mammography uses a very low dose of radiation. For most women, the benefits of having regular screening outweigh any possible risk from radiation exposure. Breast screening for women with breast implants often requires more x-ray films than for women without implants and so may involve additional exposure to radiation.

        A small risk of damage to the implant

        Radiographers take special care to use minimal compression on the breast implant during the breast screening procedure. It is highly unlikely that this compression could cause or worsen leaking of silicone or change the shape or texture of the breast, but it is possible.

        Detecting implant problems

        If you have problems with your implant, consult your doctor before coming to Breast Screen Victoria. The BreastScreen service does not investigate or diagnose conditions associated with breast implants.

        Possible breast implant abnormalities are not always obvious on a screening mammogram but, if a possible implant abnormality is incidentally noted, BreastScreen will tell you in your results letter.”

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        • Thank you for sharing that link! I still can’t get the URL to load here.

          My friend is so pleased with the feedback here.

          She also wanted me to tell the men reading this that, while the image for this article is accurate, it is only the start of the breast-flattening process. That breast isn’t even “half-squeezed” yet in the image. The idea is to get it “flat as a pancake” and the machine will do that whether you like it or not.

          She also said 20 years ago the “flatteners” were made of cold steel and hurt more than the plastic “flatteners” they use now. That was one small change she appreciated even though the process is pretty much the same.

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  • I do believe in preventative care, I just wish that mammograms weren’t so painful. I am definately not looking forward to my first one at all.

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    • Hi Brielle!

      When do you plan to get your first mammogram? Is there a threshold you hope to meet first? What does your doctor advise?

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      • My doctor and I have actually never really talked about it before. I just turned 21 in January, so I definitely am on the track of looking out for myself more, simply because of the fact that a lot of people I know who recently turned 21 had a goal of “destroying their liver” as soon as their birthday hit. ANother thing I noticed is that a lot of people that I have talked to recently have talked about going to the doctor as if it is some kind of a chore. Is that normal or is there something I am missing?

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        • Don’t destroy your liver! Don’t even start drinking. The alcohol does nothing good for your long-term health except rot you out from the inside. When I was younger, you could drink at 18 in my State — and that was just insane!

          Every State had its own drinking age for many years, until there Federally mandated law made the age 21:

          http://www.law.cornell.edu/uscode/text/23/158

          http://www.thedailybeast.com/articles/2012/06/29/what-the-supreme-court-obamacare-ruling-means-for-the-drinking-age.html

          It’s funny watching Judge Judy on TV, because she’s living in the 1980s when she was a judge in NYC and the drinking age was not universal. She still doesn’t know the age is now 21 no matter where you live — and it’s funny to wach her interrogate teenagers on the age they’re allowed to drink in their State.

          As for the chore of going to the doctor — it’s this: Once you’re in, they keep pulling you back in! They want follow-ups, they love finding little things wrong with you that they can test. They want to regularly see you and you will likely have 3-5 doctors pulling you in these directions.

          That’s all fine, but when you have to wait 1-3 hours to get in to see your doctor, people begin to lose interest, because you lose an entire day sitting in a room with a bunch of sick people. Working folk quickly use up their vacation and sick days sitting on reception room chairs because now you see specialists for every little thing and your primary doctor just becomes a hub for referrals to other medical doctors manning the spokes. It’s definitely a chore to manage your preventative health — and that doesn’t even include the prescriptions insanity you have to decipher and try to predict.

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  • That image makes me cringe in pain! A necessary evil. Not evil. Proof of life.

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