Saturday 22 September 2018

I want to keep my breasts. Screening options for high-risk women who don’t want prophylactic mastectomy.

Angelina Jolie. Christina Applegate.  These two Hollywood superstars have something in common that millions upon millions of other women also share:

Having been labeled HIGH-RISK for breast cancer, they opted to have both of their breasts removed preventatively.

If faced with the same dilemma, what would you do?

Chances are, your gut reaction would be, “take ‘em both off.”  That’s a completely understandable thought if you know that many women in your family have had breast cancer and your doctor’s analysis based on family and medical history places your risk level squarely above 20%.  Knowing there’s a high likelihood you will develop breast cancer can be scary and overwhelming. Preventative surgery -- otherwise known as prophylactic mastectomy -- can seem like a reassuring solution.

Yet the decision to go ahead with such a major procedure is far from easy. As I show in my novel, Bedside Manners, these decisions can be costly. Removing both breasts is both physically and emotionally strenuous—not to mention irreversible, and life-altering.

As a breast imaging specialist, I often have discussions with women about their breast cancer risk and what they can do about it. With so much information out there, the options can be confusing and difficult to sort through. While prophylactic mastectomy is one choice, it may not be the right one for everyone. If you are not ready to take this step, there are still many powerful screening options that will allow you to be proactive about finding any potential changes that may signal it’s time to take action:

 Annual screening mammography. This is by far the best way to make sure your breasts remain healthy and cancer free. Mammography is the only test that has been proven to save lives. If your center offers 3D mammography, also known as tomosynthesis, you should definitely choose this option. This newer type of mammogram is better at finding subtle cancers and also decreases the number of women who need to return for additional pictures.

 There are several other tests that can be used for supplemental screening in conjunction with your mammogram. By far the best additional test for high risk women is Breast MRI. This test is extremely sensitive—it finds nearly all cancers when they are small and treatable. Screening breast ultrasound, another test used for supplemental screening, is not as useful as breast MRI—it finds fewer cancers and requires many more benign biopsies to diagnose these cancers. Other screening tests such as breast specific gamma imaging are less commonly used.

 Develop a relationship with a breast specialist. Some large centers offer high-risk clinics, but in most parts of the country this will mean making an appointment with a breast surgeon. This doctor will go over your history and help you develop a screening regimen that works for you. Some women prefer to have their mammogram and breast MRI performed on the same day. Others choose to stagger these tests every six months so they are being screened at least twice a year. Your breast surgeon will also examine your breasts on a regular basis to assess for subtle changes.

 There are also several medications that can help you stay cancer free. Taking medicine to decrease your risk is known as “chemoprevention.” While these medicines have been shown to decrease your chances of getting breast cancer, they also can cause side effects such as hot flashes and blood clots. Set up a meeting with an oncologist to discuss the pros and cons to help you decide whether chemoprevention is right for you.

 Know your own breasts. While the medical professionals are important, you are the ultimate expert on your body. If you notice something feels or looks different—a lump, an area of thickening, nipple discharge—let your doctor know immediately. Also, set a time to examine your breasts at least once a month and call your doctor if you notice any changes.

It’s also important to know that women who are considered high risk can have widely different chances of developing breast cancer. Women with known BRCA positive gene mutations have been shown to have up to 72% risk of receiving a breast cancer diagnosis in their lifetime while other “high risk” women have closer to the 20% lifetime risk. Your level of risk will factor into your discussion with your doctor and help you come up with a plan to move forward with this new information.

You can do this. It’s always better to be educated and informed than bury your head in the sand. Congratulations on taking control of the situation and being proactive about your breast health.


Heather Frimmer is an avid writer and reader when not practicing radiology. Her debut novel, Bedside Manners, will be published by SparkPress in October 2018. To find out more, visit

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