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Mammography – breast cancer screening

Overview: The Department of Health and Human Services supports a wide variety of programs in research, treatment and screening for breast cancer.

Early detection of breast cancer is crucial for successful treatment, and HHS programs promote mammography and clinical breast exams. This is especially true for older women: about 80 percent of breast cancers occur in women age 50 or older, yet 33 percent of women age 50 to 64, and 45 percent of women age 65 and older, have reported not receiving a mammogram in the past two years. HHS agencies support a number of efforts to inform women about mammography, assure high quality service, and help provide access:

  • The National Cancer Institute, and other NIH institutes, provide information outreach and support broad research on breast cancer and on new breast imaging technologies
  • The Food and Drug Administration establishes quality standards for mammography facilities and certifies facilities
  • The Agency for Health Care Policy and Research has issued guidelines on the quality and delivery of mammography, and does research on mammography services
  • The Centers for Disease Control and Prevention supports an early detection program providing access to mammography for uninsured and low-income women
  • Medicare and Medicaid cover treatment for breast cancer and for screening services in most states. President Clinton proposed, and Congress adopted, the expansion of Medicare coverage which will help pay for annual mammograms for all Medicare beneficiaries age 40 and over. This new benefit will be available starting January 1, 1998.

The National Cancer Institute provides science-based guidance on the use of mammography. NCI now recommends that women age 40 and over be screened every one to two years. In addition, the institute recommends that women at higher risk of breast cancer get expert medical advice about when to begin screening and about the frequency of their screening.

Breast Cancer (history of mammogram screening tests)

Breast cancer is the most frequently diagnosed non-skin cancer in women in the United States. It is second only to lung cancer in cancer-related deaths. Approximately 180,000 new cases of breast cancer will be diagnosed in 1997, and about 44,000 women are expected to die from the disease.

Between 1982 and 1987, breast cancer incidence (rate of new cases) for women increased about 4 percent per year, but recently has leveled off. The death rate for women with breast cancer declined 6.3 percent between 1991 and 1995. The greatest reductions in death rates were among younger women (9.3 percent) and white women (6.6 percent), with more modest reductions among African Americans (1.6 percent) and women age 65 and older (2.8 percent).

There are a variety of effective treatments for breast cancer, including surgery, radiotherapy, hormonal therapy, and chemotherapy.

Breast cancer mammogram

Risk Factors

Elevated risk of breast cancer is associated with the following conditions:

  • Having had a previous breast cancer.
  • Laboratory evidence that the woman is carrying a specific genetic mutation or change that increases susceptibility to breast cancer.
  • Having a mother, sister, or daughter with a history of breast cancer or having two or more close relatives, such as cousins, with a history of breast cancer.
  • Having had a diagnosis of other types of breast disease (not cancer but a condition that may predispose to cancer) or having had two or more breast biopsies for benign disease.
  • Having so much dense breast tissue on a previous mammographic examination that clear reading was difficult.
  • Having a first birth at age 30 or older.

Breast cancer is more prevalent in older age groups. The risk of breast cancer increases with age. About 80 percent of breast cancers occur in women age 50 or older. The risk is especially high in women over age 60. Breast cancer is uncommon under age 40. Present rates project that each year, out of 100,000 women:

  • in their 30s, 43 women will be diagnosed with breast cancer and 8 will die of the disease;
  • in their 40s, 163 women will be diagnosed with breast cancer and 29 will die of the disease;
  • in their 50s, 263 women will be diagnosed with breast cancer and 59 will die of the disease;
  • in their 60s, 374 women will be diagnosed with breast cancer and 91 will die of it.

Early Detection

Screening is a means to detect breast cancer before the onset of symptoms. High-quality mammography, with clinical breast exams, is the most effective technology presently available to detect breast tumors.

Several studies have shown that regular mammography screening can decrease the chance of dying from breast cancer. In addition, early detection may prevent the necessity of removing lymph nodes and in some cases may prevent the need for removing the entire breast or for undergoing chemotherapy.

Current NCI Guidance on Mammography

The National Cancer Institute, following the advice of the National Cancer Advisory Board, recommends:

  • Women in their 40s who are at average risk of breast cancer should be screened every one to two years with mammography
  • Women aged 50 and older should be screened every one to two years
  • Women who are at higher risk of breast cancer should seek expert medical advice about when and how often they should get screened.

Along with mammograms, a clinical breast examination by a health care provider should be included as part of regular, routine health care.

Breast cancer mammogram

Limitations of Mammography

While mammography is the best screening tool available now, early detection does not necessarily mean lives will be saved. Mammography may not help a woman with a small but fast growing tumor that has already spread at the time of detection. And about 50 percent of women whose breast cancer is detected by mammography would not have died from the cancer even if they had waited until a lump could be felt because the tumors are slow-growing and easy to treat.

Breasts of younger women contain many glands and ligaments that appear dense on a mammogram, so it is sometimes difficult to spot tumors in their breasts.

About 25 percent of breast tumors are missed in women in their 40s compared to 10 percent for women in their 50s.

Also, between 5 percent and 10 percent of mammograms are abnormal. Of those in younger women that are followed up with additional tests (another mammogram, fine needle aspiration, ultrasound, or biopsy) most will not be cancer.

Over the past 30 years, mammography has been able to detect a higher proportion of small tissue abnormalities called ductal carcinoma in situ (DCIS), abnormal cells confined to the milk ducts of the breast. Some believe these tumors are not life threatening, while others think they are. Because there is so little data to support either view, the abnormalities are commonly removed surgically.

HHS is supporting a variety of research projects aimed at improving breast cancer detection.

HHS Programs Supporting Mammography

Mammography Quality Standards. Under the final rules of the Mammography Quality Standards Act (MQSA), published October 1997, the FDA sets high standards for mammography facilities and certifies those which meet the standards.

The roughly 10,000 mammography facilities nationwide certified by the FDA must meet quality standards for both equipment and personnel, and are inspected annually. MQSA regulations require facilities to hire capable technologists, use quality dedicated equipment that produces clear images, and employ skilled interpreting physicians to interpret the results both accurately and efficiently. The rules also require that doctors and patients be fully and quickly informed of results so that any follow-up testing or treatment can begin immediately.

The names and locations of FDA certified mammography facilities are available by calling the Cancer Information Service at 1-800-4-CANCER. In addition, the FDA has included a list of all FDA certified mammography facilities in the United States on its internet home page.

Research To Develop Better Screening

New imaging technologies under development for breast cancer screening include magnetic resonance imaging, breast ultrasound, and breast-specific positron emission tomography. In addition to imaging technologies, NCI-supported scientists are exploring methods to detect breast cancer using simple tests of the blood, urine, or nipple aspirates, and to detect genetic alterations that place women at increased risk for breast cancer.

In addition, HHS is working with the Department of Defense, the CIA, NASA, and other public and private entities to explore ways in which imaging technologies from other fields may be applied to the early detection of breast cancer. In particular, the computer technologies that have been used to improve spy satellites may help improve breast cancer detection as well.

Mammography Clinical Practice Guidelines

Recognizing the importance of the quality of screening mammograms in the early detection of breast cancer, HHS’ Agency for Health Care Policy and Research developed a Clinical Practice Guideline – Quality Determinants of Mammography – with separate versions for mammography providers, health care professionals, and consumers.

The guideline provides information on the roles and responsibilities of each health care professional involved in mammography services, as well as information and recommendations for women.

Breast cancer mammogram

Medicare and Medicaid Coverage of Mammography

Medicare has covered mammography screening for the early detection of breast cancer. For women age 40-49, Medicare currently covers one screening mammogram every two years, except for women with a high risk (for example, a woman with a mother, sister or daughter who has had breast cancer), in which case annual mammograms are covered. For women age 50-64, annual screening mammograms are covered; and for women 65 and older, Medicare covers one screening mammogram every two years.

Under Medicaid, diagnostic mammograms are a mandated service and states must cover them. Screening mammograms, however, are provided by states as an optional service, with most states covering screening mammograms in fee-for-service Medicaid. In addition, virtually all Medicaid managed care plans offer preventive services, including mammography, to their enrolles.

  • The Health Care Financing Administration has urged states to provide annual mammography screening to Medicaid beneficiaries at age 40;
  • HCFA will continue to provide federal matching payments for annual mammography screening services.

Breast cancer mammogram

Privacy of Medical Records and Breast Cancer

In many diseases, such as breast cancer, we are beginning to identify genetic alterations that may place a woman at increased risk. Women who test positive may increase cancer detection efforts, may elect to have preventive surgery, or may join a cancer prevention research study.

However, genetic testing also can be used by insurance companies and others to discriminate and stigmatize individuals and groups of people. In fact, studies show that one of the reasons women do not get genetic testing for breast cancer is because they fear the information will be used to discriminate against them.

Mammography for Women with Addictive and Mental Health Disorders

Women who are in need or who receive substance abuse or mental health services often lack appropriate primary health care, including breast cancer education, detection and treatment.

Women-focused substance abuse and mental health programs funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) are designed to be comprehensive, delivering primary health care services to women who often are medically underserved. These services include education on breast self-examination and mammography services, and counseling on risks for breast cancer.