Don't miss our upcoming webinars: Subscribe today! In this webinar: Dr. Paula Gordon will share information on when individuals should start screening for breast cancer, and how often to screen - in order for cancer to be found as early as possible, and to allow the least aggressive options for treatment. Dr. Gordon will also discuss how to screen for recurrence in women who’ve had cancer, explain why these methods are not always offered, and suggest what you can do to improve access to optimal screening. View the video: https://youtu.be/7uFksz6_4Zk Follow CCSN on social media: Twitter - https://twitter.com/survivornetca Facebook - https://www.facebook.com/CanadianSurvivorNet Instagram: https://www.instagram.com/survivornet_ca/ Pinterest - https://www.pinterest.com/survivornetwork

1. Breast Cancer: Optimal Screening,
Why We Don’t Get it
& The Importance of Breast Density
Paula B. Gordon, OBC, MD, FRCPC, FSBI
Clinical Professor, University of British Columbia
@DrPaulaGordon

2. Disclosures
Volunteer Scientific Advisory Boards:
Real Imaging
Densebreast-info.org
DenseBreastsCanada.ca
Stockholder:
Volpara

3. Objectives
• Describe the best time to start screening for cancer
• How and how often to screen for breast cancer so it can
be found as early as possible, to allow the least aggressive
options for treatment
• How to screen for recurrence in women who’ve had
cancer
• Explain why these methods are not always offered
• Suggest what you can do about it

4. • A disease where a group of cells loses normal control
• These abnormal cells grow, usually into a lump, and
invade and damage the adjacent normal tissue
• They can spread to other parts of the body
• Nearby or distant lymph nodes
• Lung/bone/brain, etc
• Many cancers can be found before this happens, and
when they can be more easily treated
What is Breast Cancer?

5. “1 In 8” Statistic is if we all live till Age 90
Probability of developing invasive breast cancer
in the next 10 years
• age 20: the probability is .06%, or 1 in 1,732
• age 30: the probability is .44%, or 1 in 228
• age 40: the probability is 1.45%, or 1 in 69
• age 50: the probability is 2.31%, or 1 in 43
• age 60: the probability is 3.49%, or 1 in 29
• age 70: the probability is 3.84%, or 1 in 26

6. Breast Cancer in the 40s
1 in 6 breast cancers are diagnosed in women
in their forties
41% of the years of life lost to breast cancer,
are in women diagnosed in their forties
https://www.sbi-
online.org/endtheconfusion/PatientResources
/WhyScreenat40.aspx

7. Factors that Increase Risk
• Estrogen use
• Dietary: fat, alcohol
• Lack of exercise
• Smoking
• Body Weight
• Genetic Mutation
• Chest Wall Radiation
• Dense Breast Tissue*
• Family History
• Previous Atypia or
Atypia
• Early Menarche
• Late Menopause
• Nulliparity
Factors you cannot control Factors you can control
* Dense Breast tissue is now known
to be a more important risk factor
than Family History
Engmann NJ et al. JAMA Oncol 2017

9. Why Do We Screen For Cancer?
• To save lives (reduce mortality) by finding and treating
the disease earlier
• To allow less aggressive treatment required for more
advanced disease.
• When cancer is found earlier, women can often:
• Avoid mastectomy
• Avoid axillary dissection
• Avoid chemotherapy

10. How Do We Screen For Cancer?
Breast Self Examination
Clinical Breast Examination
Mammography – 2D, 3D
Ultrasound – HH or ABUS
MRI
Breast Specific Gamma Imaging/MBI
Dual-Energy Contrast-Enhanced Mammography
Not Thermography!

11. Women are 20-49% less likely to die of breast
cancer if they are invited to have, or actually
have, screening mammography, than women
who do not.
Arleo et al. SBI Screening Leadership Group 2016
Tabar et al. Breast J 2015; 21:13-20
Independent UK Panel on Breast Cancer Screening. Lancet 2012; 380:1778-1786
Broeders et al.J Med Screen 2012; 19 Suppl;14-25
Coldman et al. JNCI 2014; 106
Nickson et al. Cancer Epidemiol Biomarkers Prev 2012; 21:1479-1488

12. Annual Screening Starting At Age 40
Saves The Most Lives
This is recognized even by organizations that
recommend starting later,
or screening less often
Mandelblatt JS et al. Ann Intern Med 2016; 164:215-225

13. Current Guidelines: When To Begin Screening
American College of Radiology: age 40
Society of Breast Imaging: age 40
National Comprehensive Cancer Network: age 40
American Society of Breast Surgeons: age 40
American College Obstetricians and Gynecologists: age 40-50,
after discussion with PCP
American Cancer Society: age 45 or 40 if women prefer
US Task Force: age 50
Canadian Task Force: age 50
Canadian Cancer Society: age 50
Conflicting guidelines did not arise because of alternative facts.
They arose because of different value judgments applied to the same
facts.

14. Evidence that Screening Saves Lives
11 Randomized Trials
• NYHIP 1963
• Malmö 1 1976
• Malmö 2 1978
• Kopparberg 1976
• Östergötland 1978
• Edinburgh 1978
• CNBSS 1 1980
• CNBSS 2 1980
• Stockholm 1981
• Göteberg 1982
• Finland 1987
And dozens of systematic reviews and meta-analyses
Courtesy Dr. Jean Seely

15. Courtesy Dr. Jean Seely

16. Courtesy Dr. Dan Kopans

17. Courtesy Dr. Dan Kopans

18. Courtesy Dr. Jean Seely

19. Courtesy Dr. Dan Kopans

20. Barnes GT. Radiographics 1991; 11:307-323
Without grid With grid

21. Courtesy Martin Yaffe, PhD
Mammogram from
Sweden 1981

23. MYTH: In the Era of Modern Therapy, it’s Not as
Important to Find Cancers Early
Conclusion:
Tumour stage at diagnosis of breast cancer still
influences overall survival significantly in the current
era of effective systemic therapy. Diagnosis of breast
cancer at an early tumour stage remains vital.
Saadatmand S et al. BMJ 2015;351:h4901 doi: 10.1136/bmj.h4901

24. The Incidence of Fatal Breast Cancer Measures the
Increased Effectiveness of Therapy in Women
Participating in Mammography Screening
Tabar et al. Cancer 2019; 125:515-523
• 52,438 women aged 40‐69 screened 1977-2015 in
Dalarna County, Sweden with 85% participation rate
• Compared to non-screened women during the same
period, and non-screened women in the prior 19 yrs
• 58 years total
• Women who chose to be screened were 60% less
likely to die in the 10 yrs after diagnosis, and 47%
less likely to die within 20 yrs of diagnosis

25. The Incidence of Fatal Breast Cancer Measures the
Increased Effectiveness of Therapy in Women
Participating in Mammography Screening
Tabar et al. Cancer 2019; 125:515-523
• 52,438 women aged 40‐69 screened 1977-2015 in
Dalarna County, Sweden with 85% participation rate
• Compared to non-screened women during the same
period, and non-screened women in the prior 19 yrs
• 58 years total
• Women who chose to be screened were 60% less
likely to die in the 10 yrs after diagnosis, and 47%
less likely to die within 20 yrs of diagnosis
“These results demonstrate that women who have
participated in mammography screening obtain a
significantly greater benefit from the therapy
available at the time of diagnosis than do those who
have not participated.”

26. In 2014, the Canadian National Breast Screening Study
released of their 25 year follow.
To understand their conclusions, you have to know that the study was
poorly designed and poorly executed.
Bear in mind, it was done in the 1980’s using obsolete technology.

27. Many experts internationally are painfully familiar with the details
of the trial and have to stay on guard to respond.

28. Evidence For Screening
Courtesy Dr. Jean Seely

29. • Data were obtained on 2,796,472 screening
participants from 7/12 screening programs in
Canada, representing 85% of the population
• 40% mortality reduction overall
• 44% mortality reduction for women 40-49

30. A Failure Analysis of Invasive Breast Cancer:
Most Deaths From Disease Occur in Women NOT
Regularly Screened
Webb ML et al. Cancer Sept 9, 2013
• 7301 women diagnosed with breast cancer
1990-1999 at 2 hospitals in the Harvard system
in Boston
• 609 breast cancer deaths, 905 non-breast cancer
deaths

31. Webb ML et al. Cancer Sept 9, 2013
• 71% of deaths occurred in the 20% of women who
did not undergo regular mammographic screening
and 29% occurred in regularly screened women
(19% screen-detected, 10% interval)
• Of all breast cancer deaths, only 13% occurred in
women 70 years or older but 50% occurred in
women under age 50; 31% occurred in women
initially diagnosed between ages 40 and 49 years

32. Mortality Reduction is the
Only Benefit that can be Seen in an RCT
But there are other benefits of early detection
• Option for Breast-conserving Surgery
• Option for Avoiding Axillary Dissection
• Option to Avoid Chemotherapy

33. Finding Cancer Early Can Mean The Difference
Between Needing A Mastectomy (Left) Or
Being Able To Have A Lumpectomy (Right)

34. Impact of Screening Mammography on Treatment in
Women Diagnosed with Breast Cancer
Ahn S et al. Ann Surg Oncol https://doi.org/10.1245/s10434-018-6646-8
• 2 groups: mammo 1-24 months prior to diagnosis, or
25+ months prior
• Women having screening mammography less often
more likely to receive chemotherapy, undergo
mastectomy, and require axillary dissection
• Patients aged 40–49 years with no prior mammography
were more likely to have larger tumors and positive
nodes, undergo mastectomy, undergo axillary
dissection and require chemotherapy than women who
had mammo in the 2 years prior

35. http://lymphademainfo.blogspot.com/20
07/08/what-is-lymphadema.html
• Swelling in the arm and
hand from blockage of the
lymphatic vessels in the
armpit: a side effect of
traditional armpit surgery
done as part of breast
cancer lymph node staging.
• This surgery can be avoided
when cancer is detected
early
Lymphedema
Giuliano AE et al. JAMA 2011;305:569–575

36. Node Staging
• Sentinel node biopsy now the standard of
care for cancers smaller than 2cm, and if
there are no suspicious nodes on imaging or
physical examination
• Less invasive
• Much lower risk of lymphedema than
traditional armpit surgery

37. Chemotherapy
Many women with early breast cancer and showing low risk of
recurrence on 21-Gene Expression Assay can avoid chemotherapy
Sparano JA et al. NEJM 2018; 379:111-121

38. Randomized Controlled
Trials
using death as the endpoint
They did not measure reduced morbidity
Suffering
Harsh Treatment
Medical Problems Created By Treatment
Proof of Benefit of Screening

39. Does Screening Save Lives?
• Randomized Controlled Trials (RCTs) of Mammography
have shown a 15-20% mortality reduction in women
invited to be screened
• Observational studies show 40-49% fewer deaths in
women who attend screening

40. “Harms” Of Mammography Screening
According to US and CA Task Forces
• Pain from compression 1-4%
• Radiation Oncogenesis < 1%
• False Alarms: recall, biopsy 5-15%
• Anxiety
• Inconvenience
• Discomfort
• False Negatives (false reassurance) < 1%
• Overdiagnosis 1-
10%
Sickles

41. Radiation Risk From Mammography
• Radiation risk of breast cancer from mammogram is
primarily in women less than 20 years old
• Mammogram (4 pictures) 0.4 mSv
• Transcontinental flight 0.08 mSv
• The higher you are in altitude, the higher the dose
of radiation. This is a result of less shielding of
cosmic radiation by the atmosphere at higher altitudes.
• The dose from a mammogram is similar to 7 weeks of
average natural background radiation (or 3-4 weeks living in
Colorado)

42. Risk vs Benefit: Radiation
• For 1000 women aged 50-69 having a
mammogram every 2 years, radiation would
hypothetically cause 0.27 cancers and 0.04
deaths
• The mammograms would prevent 5 deaths (125
times more than lives lost) and save 105 years of
life
• So avoiding mammograms for fear of radiation is
not a winning bet
Yaffe MJ, Mainprize JG. Radiology 2011; 258:98-105

44. False Alarms
• For every 1000 women screened, 93% (930) will
get a normal result
• 7% (70) will need additional tests
• The majority of these will need only one or more
additional mammographic views
• Some will need ultrasound
• 16% (11 of the 70) will need a needle biopsy. These
are done with local freezing and should be not
significantly more painful than a blood test
• 4 will be diagnosed with breast cancer

45. Screening Mammography: Do Women Prefer
A Higher Recall Rate Given The Possibility Of
Earlier Detection Of Cancer?
Ganott MA et al. Radiology 2006; 238:793-800
• 1570 women responded
• 97% believed that a false-positive result would
not deter them from continuing with regular
screening
• 86% would have been willing to be recalled more
often for a noninvasive or 82% for an invasive
procedure if it might increase the chance of
detecting a cancer (if present) earlier

46. Over-Diagnosis
• The theoretical possibility that some cancers would never
surface on their own and are only found when screening
was done, so there is really no need to know about them.
• Some cancers grow so slowly, they may never become life-
threatening (we don’t know yet, how to recognize these)
• Or a woman might die of something else, before her cancer
becomes life-threatening
• Heart disease
• A different cancer
• A car accident

47. Helvie MA. JBI 2019; 1:278–282
“Assessing the importance of overdiagnosis is a
subjective judgment that contrasts the value of
unnecessary treatment of an overdiagnosed cancer,
with the value of saving a life from breast cancer:
that is, overdiagnosis from screening versus
increased mortality by not screening (“over dying”).
Many women are willing to accept screening risks in
order to reduce the likelihood of breast cancer
death.”

48. The Canadian Task Force on
Preventive Health Care
• Recommends against routine screening
mammography in women aged 40 to 49 years
• Recommends screening mammography every 2-3
years for women aged 50 to 74 years
• Recommends against performing breast self-
examination (BSE)
• Recommends against performing clinical breast
examination (CBE)

49. courtesy Dr. Glen Scheske

50. US and Canadian Task Forces’ Rationale
Exaggerated the harms of mammographic screening
Underestimated the benefits
Then say that the harms outweigh the benefits
BUT THE HARMS DON’T EQUATE TO POSSIBLE
DEATH IF NO SCREENING

51. USPSTF
Screening Mammography Recommendations:
Science Ignored
Hendrick and Helvie. AJR 2011; 196:112-6
If women who were age 30-39 (entering their
forties over the next 10 years), follow the
USPSTF guidelines, 100,000 more would die
from breast cancer that could have been saved
by annual screening beginning at the age of 40

52. Women in Their 40’s
• Women 40-49 are not
offered breast cancer
screening in all
provinces.
• They often are caring
for young children and
aging parents
• They are working and
contributing to the
economy
They are not expendable!

53. Screening in Canada
• Seven provinces: women may self-refer every
2 years, starting at 50
• Three provinces start at 40
• In BC, women with a mother or sister with
breast cancer may attend annually
• In some provinces, women are recalled
annually if they have dense breast tissue

54. When to Stop
• RCTs included women up to age 74
• Over 6/10 years
• Women ≥ 75 years comprised 6/10% of the
screening mammograms
• 5.8 cancers per 1000 overall
• 5.9/8.4 cancers per 1000.
• 85/82% invasive
• 98% had surgery
Hartman M et al. AJR 2015; 204:1132-6
Destounis S et al. JBI 2019; 1:182-185

55. What’s the Issue with
Breast Density?

56. Radiologists are pretty good at recognizing cancer on a mammogram, when
it’s visible. Here is a cancer in a 55 year old woman and it’s jaggedy edges
are typical of cancer

57. And it is relatively easy to see cancer when the breast is mainly fatty
like in this woman. Fat is dark gray on a mammogram.

58. But as the amount of normal dense tissue (the white stuff)
increases relative to fat….

59. It becomes harder to see cancers (which are white).
It is like trying to see a snowball in a snowstorm.

60. And some women have virtually no fat, and are all dense.
Even a large cancer can be masked in these breasts.

61. A B C D
Today, radiologists grade density into 4 categories. Some provinces still use a
quartile system, where the radiologist subjectively decides what percentage of
the area is dense tissue: < 25%, 25-50, 50-75, and >75%.
BC and NS use the new system introduced in 2014: A – D, based on the
possibility of masking a cancer, so even in a breast with less dense tissue, if it’s
concentrated in a small area, can be a category D.
B

62. Negative Screening Mammogram
50 Year Old Woman with Dense Breasts

63. 8 Months later: She had a palpable mass
Repeat Mammogram was Still Negative – even with
Tomosynthesis (3D)
63

64. Her 3.2 cm cancer was not visible on her
mammogram in her dense breast tissue
But was easily seen on Ultrasound
64
• A cancer that is found as
a lump, after a negative
mammogram is called an
interval cancer.
• Interval cancers are 18X
more common in women
with dense breasts
WE SEE CASES LIKE THIS
EVERY SINGLE WEEK

65. Dense Breasts Are Normal And Common
• Every woman has fat, glands and fibrous tissue in her
breasts, but the proportions vary from woman to
woman.
• Breasts that have more than 50% glands and fibrous
tissue are called dense breasts.
• > 40% of women, aged 40-74 have dense breasts, and
the only way to tell is on a mammogram
• Breasts may, (but not always) become less dense and
more fatty with age.

66. Dense Breasts Are Normal And Common
While it is normal to have dense breasts, women
need to know if they have dense breasts so that
they can understand the implications.
• In Canada, there are 3.4 million women over age
40 with dense breasts.
• Over 800,000 women in Canada are in the
highest density category ( >75% dense breast
tissue)
• Only 60% of women have mammograms, so the
rest cannot find out their density

67. Why It’s Important To Know
If You Have Dense Breasts
• Women in the D category have 4-6 X higher risk of
developing breast cancer than women with fatty breasts
• Masking effect: dense tissue and cancer both appear
white on a mammogram, so cancers can hide
• Cancers are larger and more often node positive
• 18X higher risk of an interval cancer (cancer discovered
between screenings); these cancers have a worse
prognosis than screen-detected cancer
Pisano ED et al. NEJM 2005; 353:1773–1783
Boyd NF et al. NEJM 2007; 356:227–236
Yaghjyan L et al. JNCI 2011; 103:1179–1189

68. How is Breast Density Determined?
• Only by the radiologist when viewing a mammogram.
• Not by breast size or touch.
• Your GP cannot tell by a physical exam.
• Lumpy breasts are not the same
as dense breasts
• Both fatty and dense breasts can feel soft, firm or
lumpy.
• Some provinces such as Nova Scotia, PEI and Alberta are
beginning to use software to measure the level of
density.

69. Role of Ultrasound

70. For many years, it was believed that ultrasound could not find cancers
that were not visible on mammography, and too small to feel.
We published this paper 25 yrs ago, and it was followed by work from
multiple other institutions and then multicentre trials, that showed that
high resolution ultrasound can indeed find cancers that are too small to
be palpable, and missed on mammography, largely because of dense
breast tissue.
Cancer 1995; 76: 626-630

71. Supplemental Yield Of US: ACRIN 6666
• 5.3 cancers/1000 in the first year (p<.001)
• 3.7/1000 in the 2nd and 3rd years (p<.001)
• Average 4.3/1000 all 3 years
• 94% were invasive
• median size: 10 mm (range 2-40 mm)
• 96% of those staged were node negative
• MRI 14.7/1000 after negative M & US
• But 42% eligible women declined MR
Berg WA, et al. JAMA 2012; 307:1394-1404

72. Automated
Ultrasound
Hand-held
Hand-Held
Ultrasound

73. • In spite of all the evidence on breast
density, it was still not being shared with
women, and in many cases, with their
doctors.
• Nancy Cappello is an American advocate.
In 2004, only weeks after a routine
annual screening mammogram that was
negative, she found a lump in her breast.
After an ultrasound showed a cancer, she
was diagnosed as stage 3C with 13
positive axillary nodes.
• She lobbied for legislation to require
patient notification of density and its
impact on mammogram sensitivity, and
potential for supplementary screening.

74. There are currently 38 states with some degree of density notification in
the USA. FDA has said all women must be notified.

75. The Connecticut Experiment;
The 3rd Installment: 4 Years of screening women with
Dense Breasts with bilateral Ultrasound
• Additional yield 3.2 cancers / 1000 in year 1
• Additional yield 3.8 cancers / 1000 in year 2
• Additional yield 3.2 cancers / 1000 in year 3
• Additional yield 3.5 cancers / 1000 in year 4
• Average size < 1cm
• PPV of 6.7% in year 1, 17.2% in year 4
• Only 30% of eligible women, even though insured
Weigert J. The Breast J 2016;1-6

76. Small, node negative cancers
Not seen on mammogram, but seen on ultrasound
Courtesy Dr. Regina Hooley

77. How Do We Screen For Cancer?
• “The only screening method that has been proven to
reduce mortality is mammography.”
• It’s the only modality that has been studied in
Randomized Control Trials (RCTs)
• An RCT of Ultrasound is being done now in Japan
• Other methods for screening, used in select populations,
like Ultrasound, MRI, and MBI have not been studied for
mortality reduction.
• Yet MRI is used for screening high risk women

78. Dense Breasts Canada

79. Facebook – January 2017

80. Twitter – October 2016/ August 2019

81. Website – Mar 2018

84. How Can I Find Out My Breast Density
After a Screening Mammogram
• As of now: BC, NS, PEI notification for all women
• AB, NB committed to notifying all women
• SK, MB, ON tell only highest category
• PQ – tells physician, but not women
• NL – no notification so far
• For easy to follow instructions on how to find out your
density visit densebreastscanada.ca

85. Your Doctor May be Unaware!
• Of the greater risk of getting breast cancer, when
breasts are dense
– Having dense breasts is a stronger risk factor than a family history
– Women with dense breasts are 5X more at risk than those with
fatty breasts
• Of the greater likelihood of a cancer being missed on a
mammogram when breasts are dense
– 50% of cancers are missed in women with the highest density
• Of the ability of ultrasound to find the cancers missed
on a mammogram, when breasts are dense

86. What About 3D Mammography
(Digital Breast Tomosynthesis)?
• Finds 30% more cancers
• Has fewer false alarms
• But sees only half the cancers visible on
ultrasound, that were missed on
mammograms

87. DBT vs Screening Breast US
US detects more cancers than tomo
3 Small Invasive Cancers, not seen on 3D Mammography
Visible on Screening Ultrasound
Courtesy Dr. Regina Hooley

88. Other Technologies –MRI
Courtesy Dr. Maxine Jochelson

89. Courtesy Dr. Maxine Jochelson
Emerging Technologies – Fast MRI

90. Courtesy Dr. Maxine Jochelson
Contrast-Enhanced Dual-Energy
Mammography
mammogram CEDM MRI

91. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2748346/
MBI/BSGI

92. What Should I Do If I Have Dense Breasts?
• Continue having mammograms because they can
detect cancer not visible on ultrasound.
• Perform regular self-exams between screenings. Look
for any change that may be cancer, not seen on your
mammogram, and see your doctor.
• Consider modifying your lifestyle factors to decrease
the risk of cancer, or recurrence such as: getting to
and staying at a healthy weight, doing moderate
exercise, decreasing alcohol intake and decreasing
hormone use.

93. What Should I Do If I Have Dense Breasts?
• Speak with your doctor about: your level of density, the
associated risks, any additional risk factors you have
and the best screening options for you.
• To improve early cancer detection in dense breasts,
consider additional screening, such as ultrasound or
MRI,* especially if you’ve had cancer
• If you are diagnosed with breast cancer, consider MRI
to ensure no additional tumours are hidden, before
deciding on lumpectomy vs. mastectomy, and to check
the other breast for hidden cancer(s).

94. Mammographic breast density is associated with the
development of contralateral breast cancer
Raghavendra A et al. Cancer 2017; 123:1935-1940
• 229 stage I - III BC between Jan 1997 and Dec 2012
• 451 matched controls
• After adjustment for potential prognostic risk factors for
BC, the odds of developing CBC were found to be
significantly higher for patients with dense breasts (odds
ratio, 1.80; 95% confidence interval, 1.22-2.64 [P<.01])
than for those with non-dense breasts.

95. The Association of Mammographic Density
With Risk of Contralateral Breast Cancer
and Change in Density With Treatment
in the WECARE Study
Knight JA et al Breast Cancer Res. 2018;20
• In women < 55 the risk of CBC increased linearly with
increasing mammographic density.
• Breast density can decrease with Tamoxifen or Chemotherapy
(but not radiation)
• In women where it decreases > 10% with treatment, there
may be a lower risk of CBC (more studies needed)

96. Mammographic Density and the Risk
of Breast Cancer Recurrence After
Breast-Conserving Surgery
Cil T et al Breast Cancer Res. 2018;20
• Post lumpectomy and radiation, overall risk of local
recurrence is ~ 10-15% in 10 years
• Patients with high mammographic density experienced a
much greater risk of local recurrence (21%)compared with
women with the least dense breasts (5%)
• The risk of local recurrence at 10 years was higher for women
who did not receive radiotherapy (22%) than for women who
did (10%).
• Important if considering partial breast irradiation

97. Breast Cancer Screening in Women
at Higher-Than-Average Risk:
Recommendations From the ACR
Monticciolo DL et al. J Am Coll Radiol 2018;15:408-414.
• For women with genetics-based increased risk (and their
untested first-degree relatives), with a calculated lifetime risk
≥ 20% or a history of mantle radiation therapy at a young age,
supplemental screening with contrast-enhanced breast MRI is
Recommended
• Breast MRI is also recommended for women with personal
histories of breast cancer and dense tissue, or those
diagnosed by age 50.
• Others with histories of breast cancer and those with atypia
at biopsy should consider additional surveillance with MRI,
especially if other risk factors are present.

98. Take Away Points - Breast Cancer Screening
• Optimal screening: mammograms, ideally annually
starting at age 40, and should continue as long as in
good health, with a life expectancy of at least 10 years.
• Some cancers are not detectable on mammograms
• Most abnormalities on mammograms are NOT cancer
• Woman who have mammograms are 40% less likely to
die of breast cancer….
• 3D mammography finds more cancer than 2D, and has
fewer false alarms
The benefits outweigh the harms

99. Take Away Points
Breast Cancer Screening
• Ultrasound finds cancer missed on mammograms in dense
breasts, even if 3D mammo used
• Having dense breasts poses 2 risks:
• dense breasts increase the risk of getting breast cancer
• and reduce the accuracy of mammography
• It is important to know your breast density and understand
the implications. Please speak to your doctor about your risk
factors.
Please tell your friends, family and colleagues
what you learned about screening and density.

100. For more information on breast density
visit:
www.densebreastscanada.ca

101. Canadian Cancer Survivor Network
Contact Info
Telephone / Téléphone : 613-898-1871
E-mail: jmanthorne@survivornet.ca or
info@survivornet.ca
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