Courtney Collen (Host): Hi, welcome to the Health and Wellness Podcast by Sanford Health. I’m your host Courtney Collen with Sanford Health News. We are continuing an important conversation all about breast cancer as 1 in 8 women will be diagnosed with breast cancer in her lifetime.
I’m so happy to have Dr. Christina Tello-Skjerseth who is a radiologist at Sanford Health in Bismarck, North Dakota. And we are talking all about that breast cancer screening, the mammogram Dr. Tello-Skjerseth, thanks so much for being here.
Dr. Christina Tello-Skjerseth: Thank you for having me. I’m happy to be here.
Courtney Collen (Host): So let’s start with the most basic. What is a mammogram?
Dr. Christina Tello-Skjerseth: That’s a great question. So a mammogram is a special X-ray of your breast and we do it bilaterally, which means both breasts. Every year, they get that special X-ray. There’s a special machine that takes the images. It’s not just your regular X-ray machine like when you get a chest X-ray. It’s a special unit that’s just for evaluating the breast tissue and taking breast images.
And there is a difference between a screening mammogram and a diagnostic mammogram. A screening mammogram: you come in with no symptoms, whatsoever. You’re not having any breast lumps or breast pain. You’re just there for your normal screening exam. A diagnostic mammogram, however, is different. You come in for that when you actually have a breast symptom. Now it does use the same machine to take the images, but the difference is for a screening mammogram, we’re just taking two images of each breast. For a diagnostic mammogram, you take images, you take usually three or more images of each breast and they’re shown directly to a radiologist and then they guide whether or not you need additional imaging with the mammogram or if you’re going to go on to ultrasound right away. Whereas a screening mammogram, essentially, you get those done, you leave and those images get put into a queue or, you know, essentially a pile of other mammograms and then we radiologists read those in packs.
Courtney Collen (Host): So how do we know when it’s time to come in for that very first mammogram?
Dr. Christina Tello-Skjerseth: Well, there are a lot of guidelines out there. The ones that we follow here at Sanford are the American College of Radiology, the Society for Breast Imaging, the American Congress of Obstetricians and Gynecologists, as well as the NCCN guidelines, which is the National Cancer Comprehensive Network. And they all recommend beginning annual screening mammograms at age 40. And the reason why we support those guidelines is because we have done the extensive research and reading into all of the different literature out there that’s been performed, all of the studies. And we know that when you start screening at age 40 and do it every year, that has the greatest mortality reduction. What that means is the risk of dying from cancer decreases significantly if you start at age 40 and do it every year. So those are our recommendations.
Courtney Collen (Host): OK. That’s great to know. And would there be any reason someone needs to go sooner than age 40?
Dr. Christina Tello-Skjerseth: Absolutely. That’s another great question. These recommendations are for women who have average risk of breast cancer. An average risk is 1 in 8 women in their lifetime essentially will get breast cancer. Now, if you’re at a higher risk, if you have significant family history, like a number of a female relatives or male relatives that have had breast cancer before, maybe specifically, your mother, your sister, close relatives, and even sometimes, you know, those in your extended family, that could possibly indicate that you’re high risk.
There’s also a number of gene mutations out there. Almost everyone has heard about BRCA one and BRCA two or BRCA gene mutations, but there’s about 30+ other gene mutations out there that can be associated with a higher risk of breast cancer, as well as other types of cancer. Another risk factor, if you have dense breasts, meaning that you have more of that glandular breast tissue that can increase your risk. If you’ve had a childhood cancer like lymphoma or Hodgkin’s lymphoma or leukemia, where you’ve had radiation to your chest for treatment, that can increase your risk.
So there are some very specific risk factors out there that insurance companies will follow and that the American Cancer Society and other organizations follow, as well. And if you have more than a 20% increased risk based on those risk factors, you fall into the high risk category and you should probably start screening earlier than 40.
Now, if you have one of those known gene mutations, we recommend you start getting annual screening MRI at age 25 and then you start your annual screening mammography at age 30. So it depends on a lot of different things. As a general rule, we usually say you should start screening 10 years before the youngest close relative of yours had breast cancer. So for example, if your mother had at age 40, you should start mammograms at age 30 and probably also start your annual screening MRI in conjunction with your mammogram.
Courtney Collen (Host): Let’s prepare for that first appointment. Tell us some do’s and don’ts to keep in mind.
Dr. Christina Tello-Skjerseth: Sure. You know, so again, I want to stress the fact that these are screening mammograms, not diagnostic mammograms. So a screening mammogram means you have no breast symptoms. So when you’re getting ready to schedule your mammogram, make sure that, you know, you’re feeling well, you don’t have any of those symptoms like a breast lump, nipple discharge, breast pain, things like that. If you do, then you want to make sure you see your doctor first and get scheduled for a diagnostic mammogram.
Sometimes, you know, based on your age, if you still have your menstrual cycle, there can be certain times of the month where your breasts might be a little more tender or even more glandular tissue so that can change what your breast looks like on the mammogram. Now, there isn’t a set guideline as to when you know you to get your mammogram during your menstrual cycle. It’s usually whenever you want. And then us radiologists, you know, know when you have it and know what to look for on the mammogram, but, you know, personally, if you’re feeling a little more tender or having pain, you might want to hold off until that goes away, based on your cycle.
Another thing to know is if you have had a recent immunization or a shot, like a flu vaccine or a COVID vaccine, that can cause a reaction in your lymph nodes or your glands up in your armpit area, which we call the axilla and we can see those lymph nodes on the mammogram, and they can be enlarged because your body’s reacting to the shot you got in your arm. So you might want to hold off just a little bit if you’ve had a recent shot.
The other thing is, you know, wearing deodorant, we can see the calcifications in the deodorant on the image. If you do wear deodorant the day of your mammogram, we’ll probably ask you to wipe it off with a wipe. So, other than those, you know, do’s, and don’ts as far as what to expect on your first mammogram. Here in Bismarck, our mammogram center is here in the hospital, we have other clinics in the area that also have mammography, but majority will be down here at the hospital.
Courtney Collen (Host): OK. So now it’s time for that first appointment. Walk us through the experience of that first mammogram and what that appointment looks like at Sanford Health.
Dr. Christina Tello-Skjerseth: So you’ll come in and go through your routine check-in procedure. Then you’ll change into a gown that opens in the front, and then you’ll wait in the waiting room. We’ll call you back. That is usually one of our radiology technologists who is specially trained in mammography. They will ask you some questions, you know, how you’re feeling that day, if you have any breast complaints, pain, discharge, lump, anything like that. They might ask you some of your risk factors, if any of your family history has changed recently, maybe a new member got diagnosed with breast cancer or a type of cancer. They’ll ask about how many kids you’ve had, how old you were when you first had your first child, cause all that can affect how much estrogen or hormones in your body and that can affect again, risks of breast cancer and how your tissue looks.
So you’ll be asked some questions as you walk back. Then we take you to our room that has that special mammogram camera to obtain the images. They’ll have you clean off your armpit area, usually, to get all that deodorant off.
And then we’ll take two pictures of each breast during the picture or the image acquiring process. There’s a paddle that comes down and compresses your breast tissue. Now, this is the part where some women will say really hurts and they hate having mammograms because of that pain. It’s very variable and subjective. You know, some people just say it’s a light pressure. Some people cry in pain, it’s very variable. So that’s something to expect.
And the reason why we compress the breast tissue is one, so we can spread all the tissue out as much as possible. So we can look for those tiny cancers if there are any hiding in the breast tissue. We also do that compression so that you don’t move because motion can blur what we’re seeing on the mammogram. And we want to be able to see everything so we can find those tiny early cancers if they’re there.
Now, there are two types of mammograms that are used in the U.S. One is called the 2D mammogram, which is probably what everyone has been used to. There’s also a 3D mammogram, which has been in the news, you know, for years. We call that tomosynthesis. What that means is, instead of just taking a flat 2D image of the breast, we’re taking multiple images of the breast at different angles. Then those images get stacked by the computer and they give us an image we can actually scroll through. So we’re looking at each millimeter of tissue, not just one flat image of the breast. So, that allows us to see through some of that dense tissue that could possibly have hidden the cancer.
So with 3D mammography, which we do a 100% of the time here at Sanford across the enterprise, when we do that, we find those early tiny, more advanced cancers because they don’t hide as much in that dense tissue. So most patients will be getting that 3D mammogram. Insurance does cover it. There are a few insurances that maybe don’t cover it. So if that’s the case, they’ll probably get that traditional 2D mammogram. Now you won’t know a difference between getting one or the other as far as how long you’re in compression or any other differences. Really, the camera does moves above your breast a little bit when you’re getting a 3D, but it doesn’t increase the amount of pain, or how long you’re in compression.
And then after that, we take you out of the machine, make sure you’re okay, and then you go on your way. If it’s a screening mammogram, those images get put into a pile with a bunch of other patients and then us radiologists will read them in packs during the day. And then you’ll get a message when the mammogram final report is ready for you.
Courtney Collen (Host): What are other common questions or things we should know as we prepare for that first appointment?
Dr. Christina Tello-Skjerseth: Yes. So I will tell you if you’re scheduled for your first mammogram and you’ve never had a mammogram before, what that means is we just have those first images. We have nothing to compare it to until you get your next mammogram. So when we don’t have any comparisons, what that means for us as radiologists is that we don’t know what your breast tissue normally looks like. So there is a higher rate of callback, meaning we’re going to, we’re going to find some things that may be abnormal. We don’t know. And that you’ll get called back to take additional images, which is the diagnostic mammogram, maybe even an ultrasound, maybe even a biopsy. So, a lot of people get concerned when they get called back, especially for their first mammogram. So our technologists tend to tell people now, “Hey, if this is your first mammogram, don’t get too excited if you do get called back for something, because we have no other priors.” You know, it was someone who is 65 and who’s been getting mammograms for, you know, 15, 20-some years, we have a lot of priors to go on. But someone who’s 40, we don’t have anything to go on. So there is a higher rate of call back.
The other thing I will tell women in general is, you know, that the recall rate or the callback rate nationwide is about 10%. So 1 in 10 women getting a screening mammogram will get called back for additional imaging, meaning that we’re seeing something that we’re not sure what it is. It could be a cancer. Mostly it’s usually gonna be something benign, but 10% will get called back for more images. And 10% of those that are called back will go for a biopsy. And about 20% of those patients will end up being cancer. So 80% of biopsies are normal. That does change a little bit based on your age. You know, if you’re between 40 and 50 or 50 and 60, et cetera, it does increase the older you get. But I always tell women, don’t get too excited if you get called back for something. Cause again, the chance of it being anything cancerous are pretty, pretty tiny.
Courtney Collen (Host): And finally remind us why it is so important to get this done.
Dr. Christina Tello-Skjerseth: Sure. So I’d like to stress the importance of annual screening mammograms beginning at age 40. So 1 in 8 women in their lifetime will get breast cancer. Now the average age or median age in the U.S. is age 63. However, we do see a lot of women in their 40s, even younger than 40 that do get breast cancer. And honestly the vast majority of them don’t have any high risk factors. So, while we know that the older you get, you know, the more likely you’re at risk of having breast cancer, what we’ve found through decades and decades of well-researched literature and studies is that the greatest mortality reduction for breast cancer occurs when you start screening at age 40 and do it every single year. And that mortality reduction means your chance of dying from breast cancer decreases significantly. That’s because we’re finding them earlier when they’re less aggressive and usually more treatable. So that is the goal of screening mammograms to save lives. We want to do it as soon as possible and as efficiently as possible. So, start at age 40 and do it every year.
Courtney Collen (Host): Wonderful information and a great way to wrap up. Dr. Tello-Skjerseth, thank you so much for this wonderful insight into the mammogram and reminding us when to start, why we’re doing it and we appreciate all that you do at Sanford Health up in Bismarck. Thanks, again.
Dr. Christina Tello-Skjerseth: Thanks so much. It’s my pleasure. Happy to be here.
Courtney Collen (Host): This was another episode of our podcast series One in Eight by Sanford Health. I’m Courtney Collen. Thanks for being here. Stay well.