Between mammograms, ultrasounds, and MRIs, the breast imaging landscape can be  confusing to navigate. Throw in questions like when should you start screening, how often should you go, and which technique is best for you, and the field can become even more muddled. 

Dr. Robyn Roth is an NJ-based board-certified radiologist and Associate Professor of Breast Radiology. She is also Founder of The Boobie Docs, where she creates educational content about early breast cancer detection and breast cancer risk, and author of her children’s book, Everyone Has Boobies!.

Dr. Ann L. Brown is the Section Chief, Breast Imaging at the University of Cincinnati College of Medicine and a board certified breast radiologist who is passionate about patient advocacy and has worked locally to improve breast screening. 

The Peak sat down with Dr. Roth and Dr. Brown at the Society of Breast Imaging (SBI)’s 2024 annual symposium to go over the crucial role breast screening plays in cancer prevention and early detection, myths and best practices, emerging technologies, and how Breasties can play an active role in their care.

THE PEAK: Why is breast screening so important?

DR. ANN BROWN: The whole idea with screening is that we detect breast cancer before there are any symptoms, before there’s a lump that you can feel, before you notice skin thickening, or a change in the shape of your breast, the size of your breast, or any nipple discharge.

If you do notice them, you should bring them immediately to your health care provider and have a conversation about what could be causing those symptoms. But again, the importance of screening cannot be underestimated.

The importance of universal screening is because of how common breast cancer is: one in eight women will be diagnosed with breast cancer in her lifetime, and if we knew who that one was going to be, we wouldn’t need screening mammography. We wouldn’t need supplemental screening for women with dense breasts or those who are at increased risk for developing breast cancer. But we are not at a place where we know who’s going to develop breast cancer.

TP: You are both really passionate about education both for patients and providers. What are some of the biggest gaps in knowledge that you’re seeing right now?

AB: I think one of the biggest gaps we’ve identified with our patients is in regards to breast density: what that means as far as the patient’s individual risk and then what additional screening is necessary for those patients. 

DR. ROBYN ROTH: I think that understanding breast cancer risk factors is one of the most important takeaways, especially with regards to The Breasties.

The Society of Breast Imaging (SBI) actually recommends that all women have a breast cancer risk assessment by age 25—definitely before age 30—so we can identify the high risk individuals who might benefit from earlier and supplemental screening with MRI and starting mammography earlier.

TP: What is a breast cancer risk assessment? 

AB: It has a lot to do with understanding who your patient is from the provider standpoint. It’s knowing about some soft risk factors, like what age you were when you started your period, your family history, your ancestry. It’s not that all patients should know their genetic risk factors, but it has a lot to do with just knowing your individual risk factors. 

RR: I always tell patients that if they haven’t had it done with their doctor, then they can do it themselves. There are easy online calculators, like the Tyrer-Cuzick model, where you can put in your family history, if you were ever pregnant, when your first period was—as much as you know, including your breast density.

That will calculate your breast cancer risk score. If you’re over 20 percent, then you are considered high risk for breast cancer. You could be at high risk for breast cancer and be genetically negative for a variant. That’s an important takeaway as well. 

But I want to also emphasize the important fact that most people who are diagnosed with breast cancer do not have a family history or known genetic mutation and may not be at high risk based on the calculator. That’s why I am a firm believer in the monthly self-breast exam. I think it really plays a role, especially because we’re seeing a rise in young breast cancers who may not be being screened traditionally with those modalities. 

RELATED: The Breasties Guide: How to Do a Breast Self-Exam

AB: That’s a huge piece. There are no formal guidelines recommending it anymore which, we know from doing this every day, women come into the clinic and they have found their own breast cancer. I applaud them for paying attention. They save their own lives many times. It’s important information to keep out there in circulation. 

TP: If someone learns that they have dense breast tissue, what should they do?

AB: I want to reassure any woman who [is told they have dense breast tissue], that it is normal. About half of the screening population has dense breast tissue.

It’s more common in younger women and those who have family members with dense breast tissue. We know from twin studies that it’s inherited, so you get it from your mama. But it’s not abnormal, and it’s just important to know for your own health that it is a small increased risk factor for developing breast cancer in your lifetime.

It can mean a number of different things for the individual. At the very least, it means that you should be getting a 3D mammogram every time that you get screened and you should have a conversation with your healthcare provider who knows you best about your other risks and whether you should be getting supplemental screening. 

That’s because with dense breast tissue, you may have an increased risk for breast cancer or a lifetime risk greater than 20 percent, which would mean that you are at high risk for breast cancer and those patients should without question be getting supplemental screening that’s additional to the mammogram every year with breast MRI. A breast MRI is the most sensitive test that we have for detecting breast cancer early.

RR: And if you don’t have access to MRI, ultrasound or contrast mammography is a good supplement to that as well.

TP: How does contrast mammography differ from a regular mammogram?

RR: Contrast mammography is like a mammogram and an MRI had a baby. It’s basically a low dose mammogram that uses subtraction imaging to make an enhanced mapping of the breast. Normal tissue should look completely normal but if there’s any abnormality, then we would see some abnormal enhancement in that area. Then we would look at that under ultrasound and possibly do a biopsy under one of those imaging modalities. 

It’s not FDA approved for screening at the moment. It’s really used in the diagnostic setting, but I think we’re going to see it a lot more. I think in the near future we’re going to have it for screening and it’s going to be more widely accessible. 

The only limitation is that you need a contrast injection, so it is a little bit more invasive than a routine mammogram, but it does give us beautiful pictures and it really helps overcome breast density on a mammogram.

It can be harder to biopsy things on a contrast mammogram that you find, and it might lead to an MRI or some other testing. But that’s on a case-to-case basis. But overall, I think it’s a really great imaging test. 

AB: It’s an exciting, emerging technology. In our region, in southwestern Ohio, no one is currently offering it, but I see that as we’re getting more familiar, more data on this, that it is going to be a great tool.

TP: What role does age play in breast cancer risk and screening?

AB: We need to dispel the myths about being too young. Unfortunately we are seeing younger and younger women diagnosed with breast cancer even before the age that we would traditionally recommend screening. It’s really important for our women of color. They are 72 percent more likely to be diagnosed with breast cancer before the age of 50.

RR: Starting at 40 and screening every year saves most lives in average risk women. We know that there’s a large population of people that need to start breast cancer screening before the age of 40.

If you are high-risk for breast cancer—more than a 20 percent lifetime risk—we would start breast cancer screening as early as age 25 with MRI and mammography at age 30, usually alternating every six months. A good rule of thumb is to start breast cancer screening 10 years before a first degree relative that was diagnosed with breast cancer, but not before ages 25 and 30 respectively. 

At this meeting, they talked a little bit about an individualized breast cancer screening approach and I think that’s where we’re headed. AI will definitely play a role in that as well.

I think that’s really a takeaway as well. Everything needs to be individualized and personalized for you, based on your risk factors, and how motivated a patient you are, as well. 

TP: What do you think about the potential of AI for breast imaging?

AB: I’m very excited. There has been a lot of talk about AI for a long time without any tangible applications, but what we’re seeing now is that it could be the radiologist’s best friend and a tool to make us more efficient.

Patients want information. They want good information and they want it quickly. AI is going to help us be able to basically keep up with the clinical demand because we see our volumes growing every year. 

It’s a fantastic thing, as more patients are learning about the importance of breast cancer screening, they are coming for not only their mammogram but additional tests. We need AI to help us keep up and inform patients in a timely fashion. Our goals are always to to not delay workup and diagnose breast cancer as quickly as possible. 

RR: AI is not going to replace radiologists, but radiologists that use AI are going to replace radiologists that don’t. It’s only going to make us better and more efficient.

It’s an exciting time and there are a lot of exciting technologies down the pipeline that are only going to make us better at finding small cancers. 

TP: There is a lot of conflicting information around breast imaging on social media. What should we keep an eye out for?

RR: One of the important take homes from this meeting is that there was no talk about QT imaging or thermography or whole body MRI for breast cancer screening. There really is no role for that In breast cancer screening. 

It’s actually quite dangerous because there are influencers or doctors on social media that will try to dissuade you from getting a screening mammogram, scaring you away saying that they cause cancer and that’s not true. The benefits outweigh the risk of screening mammography.

Most of them are trying to sell you a new imaging modality that is not approved. I always encourage patients that when they hear information on the internet that it goes against everything their doctors are telling them, look at where the source is coming from. Are they trying to sell you something?

AB: Read the fine print. Your thermogram report says that it cannot be interpreted in the absence of a screening mammogram. They are selling you something that is only going to detect a fire coming out of the window. It doesn’t detect a fire inside the house. 

RR: Often, I will see patients because they had a normal thermogram and now they have to get the standard workup of a mammogram and ultrasound. It really puts us in a bind because this was never approved in the first place.

AB: It’s just an additional cost then to the patient on top of all of what we would traditionally recommend. 

TP: How should people with a personal history of breast cancer be screened or followed? 

RR: Women who have had a history of breast cancer—especially if it’s premenopausal breast cancer—and have dense breast tissue are considered high risk and should be getting an annual breast MRI or contrast mammogram, in addition to their routine screening. 

People who had a mastectomy or reconstruction are not routinely screened with imaging after those surgeries and that can be a scary thing, especially after you’ve already had breast cancer. 

That’s where the physical exam really comes into play. A monthly self breast exam is important for everyone, but especially if you’ve ever had a mastectomy and you’re not getting the routine screening, because that’s how we’re going to catch a recurrence. 

If you find something, bring it to the attention of your doctor. I always encourage people to let the doctor do a good physical exam, but if they say, “It’s nothing, don’t worry about it, it’s just a cyst,” ask the next question: “Is there any imaging test that we can do to make sure that this is not something more serious like breast cancer?” 

We just have to empower and educate people about these conversations because you don’t know without imaging and I think that’s where imaging really plays a role.