By Laura Freeman

Advances in breast cancer screening and treatment have made a tremendous difference in outcomes. Between1989 and 2020, death rates have gone down 43 percent. However, for populations most at risk for more aggressive and earlier malignancies, detection is still often coming too late.

To give more women a better chance to be survivors rather than statistics, guidelines for best practices in screening are being enhanced. New tools and strategies are aimed at finding these cancers earlier when they are more treatable.

“For women who have no additional risk factors or family history of breast cancer, the usual recommendation to begin mammography screening at age 40 still stands,”assistant director of UAB’s radiology residency program, Stefanie Woodard, DO said. “However, patients from ethnic backgrounds at greater risk of triple negative cancers, genetic mutations linked to more aggressive cancers, or earlier changes in breast tissue should begin screening at age 30.”

Although African-American women have a slightly lower overall incidence of breast cancer than non-Hispanic whites, the American Cancer Society data shows that they are 42 percent more likely to die from the disease. Death rates are also higher among Native American, Alaskan Native and Hispanic populations. Women with an Ashkenazi Jewish background, descended from Jews who settled in the Rhinelands of western Germany and northern France in medieval times, are also at higher risk of a BRAC mutation linked to aggressive breast cancer.

“Patients who have a close relative diagnosed with breast cancer should also be referred for early screening,” Woodard said. “If the relative’s cancer occurred at an early age, the patient and her doctor may want to consider beginning screening up to ten years before the relative’s cancer was diagnosed so that any changes can be detected as early as possible.”

In addition to weighing genetic influences in deciding when screenings should begin, physicians may want to consider age, tissue density and past findings in deciding which type of screening to order. Woodard’s area of expertise is in breast cancer screening and imaging, a field that has been expanding and is refining the diagnostic toolbox to provide a more precise screening.

“Breast tissue tends to be denser in younger patients, and ultrasound or breast MRI may offer a clearer, more definitive view,” she said.

MRIs can provide a 3D view and in women with variations in tissue, it can be helpful in distinguishing between fluid-filled cysts, suspicious anomalies and harmless anatomical differences unique to the patient.

“One of the options physicians may want to consider when ordering for patients at higher risk and those who have issues that might make getting a clear image difficult is a contrast enhanced digital mammogram (CEDM),´ Woodard said. “It’s much like a regular mammogram, but with dye to make difference in tissue clearer. It is faster, less expensive and less stressful than an MRI for patients who may be a bit claustrophobic. It could also provide the information needed to avoid the worry and expense of an unnecessary follow-up procedure.”

“Mammogram technicians are well-trained to work with each patient’s individual anatomy to get a clear image. Since large breasts aren’t dense, they aren’t usually a problem as long as all tissue can be included in the images. Implants can also usually be shifted to allow traditional mammography. If the patient’s breasts are angled outward with tissue farther back toward the arm, technicians may include a third view on each side to make sure everything is visible.”

Although breast cancer is usually considered a disease of women, it can occur in men, which is an important point to keep in mind in evaluating symptoms in the chest area of male patients. Another consideration physicians are seeing more often is breast care in transsexual patients who are transitioning.

“A female to male transition with top surgery that removes all breast tissue also reduces the risk of breast cancer. A male to female transition with hormones over an extended period would create a need for regular screening,” Woodard said.

In addition to regular screenings, it can make a big difference for a patient when her provider explains what her lifetime risks of breast cancer are. Not everyone has a grandmother or great aunt to ask about family history. Basic genealogy genetic tests like 23 and Me or Ancestry may be able to provide clues to some mutations, but there are many other genetic, health and lifestyle factors that can influence risk.

That’s where a new type of clinic usually found at a larger medical center may be able to help. “UAB has a breast cancer risk evaluation clinic that can combine current health data with biomarkers, personal history, family history, if known, and even genetic testing to give patients a better sense of their risks and the factors they can change for the better. This gives patients and their physician a starting point for developing a screening plan and working toward a healthier future,” Woodard said.