Guidelines regarding breast exams and mammography for the woman at average risk of breast cancer really have not changed. Many questions have been raised regarding when to start, when to stop or intervals at which time exams and/or mammograms should be performed. Major medical organizations caring for women, including the American College of Obstetricians and Gynecologists, still recommend annual clinical breast exams, self-breast awareness more so than regular self-breast exams (simply being aware of any visible or palpable changes in the breast) and mammography at the appropriate age and interval based on that individual woman’s risk.

So the focus becomes the individual woman and her risk of breast cancer, allowing that earliest detection to be the best protection long-term. The woman at average lifetime risk, about 12 percent in this country, is still advised to undergo baseline mammography at age 40, and then at intervals based on annual updates and discussion with her health care provider until beginning yearly mammography at age 50. The annual exam is a great time to make sure that any pertinent family history or other risk factors are updated and discussed. There is little evidence of benefit continuing annual mammography after age 80 in a woman with no pertinent history of breast disease.

This group of women at average lifetime risk accounts for 75 percent of all breast cancer cases — the vast majority. So who is above average risk?

A woman who has a first-degree relative with either breast or ovarian cancer, has a history of an abnormal breast biopsy, or has a history of radiation to the chest (usually from lymphoma treatment) is considered to have an elevated lifetime risk of breast cancer at 20 percent or greater. Previous mammograms with a designation of either heterogeneously dense or extremely dense breasts (at least 40 percent of the population) also increases a woman’s risk of breast cancer to some extent. This group may well benefit from studies beyond the basic 2-D mammography, to include either 3-D mammography (breast tomography) or potentially breast MRI, at appropriately determined intervals. They may benefit from medications to reduce that lifetime risk of breast cancer, as well.

The subset of women with lifetime risk of 75 percent or greater — often already identified as having hereditary cancer syndromes — or a first-degree relative confirmed as such — definitely benefit from being identified at a very young age. Every woman should be sure to update any family history regularly, not just ovarian or breast cancer, but also colon cancer, cancer of the uterus, even pancreatic cancer, both maternal and paternal sides. Those patients with appropriate genetic panel testing — not just for those BRCA gene mutations — benefit from additional imaging beginning at a younger age, at shorter intervals, and potentially risk reducing surgical intervention at the appropriate time.

As far as women with dense breasts identified on previous mammograms, continuing annual screening with 3-D mammography has been shown to be of benefit. In this group, there has been a significant decrease in call backs for additional studies, as well as unnecessary biopsies with use of the 3-D technology. Many states, including North Carolina, have laws that require the patient be advised if indeed her mammography shows dense breasts. This is a discussion to then have with your health care provider, regarding the best screening techniques for you.

The take-home message is to do everything in your power to determine whether you are average risk, versus higher risk, and make an educated decision with your health care provider — taking into consideration all risk factors including family history, regarding the best screening tool for you, as well as the appropriate interval for that examination.

3-D mammography is readily available in our area, including at Vidant Women’s Care, 1204 Brown St., Washington, as well as Eastern Radiologists in Washington and Greenville, and Carolina Breast Imaging in Greenville.

Brenda Peacock, MD, is a gynecologist at Vidant Women’s Care, Washington.