What My Abnormal Mammogram Taught Me About Women’s Breast Health

Black women and women with dense breasts- Pay attention!

Sohkor Solanke

This past June, I went in for my annual screening mammogram- another thing to check off my self-care to-do list. I left the diagnostic center within 30 minutes and thought nothing more of it.

Three days later, I received a mammogram callback from the radiology center. The call didn’t concern me too much as I had a similar call nine years ago following my first screening mammogram at age 40. Back then they saw some abnormalities on my breasts, but since it was a baseline mammogram, they had nothing with which to compare it to determine if the findings were truly abnormal or just normal for my body. After a second mammogram four days later, they concluded that everything looked fine and they would continue to monitor me to ensure the findings were stable. Two years later, everything had remained stable, and I was able to settle into a schedule of annual screening mammograms.

Because of the outcome nine years ago, I wasn’t overly concerned by this most recent callback. At least, that’s what I thought at the time. Upon reflection, I realized that I was so unnerved by the call that I couldn’t recall the details. What did she say they had found on my mammogram? It was the tone of the caller that unnerved me: She sounded caring, but also serious and concerned.

I didn’t worry too much about it for the next few days and went about my daily schedule. That suddenly changed when, four days after the callback, I was able to access my mammography records online going back to that first one almost ten years ago. I finally remembered what she had told me a few days prior: “Distortion in the right breast”. There it was listed clearly in the report. That first mammogram from almost ten years ago also found an abnormality in the right breast, although that was later proven to be nothing- apparently.

Being able to access your patient records and reports online is a double-edged sword: On the one hand, it’s good for patients to be proactive and aware of their own healthcare issues. Conversely, we’re not doctors! When we’re able to access our blood work or test results before a doctor has the time to review them with us, all types of WebMD-induced panic sets in.

I was given the first available follow-up appointment; nothing sooner was available anywhere within the county. At the time, I was fine with that and thought nothing of it. But now that I had access to my mammography reports, I realized that two and a half weeks was a long time to Google information about distortion, abnormal mammograms, and breast cancer. This is when the stress and anxiety ramped up as I drove myself crazy with worry watching YouTube videos and reading articles, some of which were actually intended for medical students and contained information that went way above my head. I couldn’t focus on the things I was supposed to be doing, and I walked around with a constant sinking feeling in my stomach. Each time I passed my bathroom mirror, I would examine my left breast, feeling around for what they had seen on my films, even though I knew that what they had seen was not palpable.

Fear gripped me as I remembered that my healthy 46-year-old cousin was suddenly diagnosed with cancer and passed away within a year of her diagnosis, leaving behind a husband and three children. Not to mention how my mother was fine one day and then not fine the next: acute leukemia ravaged her body rapidly, granting her just one month from diagnosis to death.

I also grappled with the question of the sudden appearance of this finding when last year’s mammogram was fine. Was this a result of taking hormones to manage menopause symptoms? The research seems to be mixed on the link between hormones and breast cancer. Was it even possible for hormones to cause something to develop in the space of 12 months? I also wondered if this finding had been there last year but was obscured by dense breast tissue, only picked up this year as I switched from 2D to 3D mammography, which I have learned is more sensitive at picking up subtle findings.

There’s a fine line between using the internet to educate yourself on your health issues and taking in so much information that you drive yourself crazy with worry and convince yourself you’re dying. Now I understand why the doctor who diagnosed my mother’s leukemia advised us to stay off Google following the diagnosis.

In the midst of my anxiety-inducing web searches, I did, however, find some very useful information, and I’m actually disappointed in myself for not taking the time to educate myself about my breast health before this “scare”. Now, as you read these, remember that I am in no way, shape, or form a doctor or any type of medical professional- just an eternal student who loves to research and learn new things:

Mammogram Call-backs

• Ten percent of screening mammograms result in a callback.

• Callbacks are more common with the first screening mammogram as there is nothing with which to compare any concerning findings.

Breast Density

• When you get a mammogram, the radiology report will categorize the density of your breasts into one of the following Breast Imaging Reporting and Data System (BIRADS) rankings (1):

A: The breasts are almost entirely fatty

B: There are scattered areas of fibroglandular density

C: The breasts are heterogeneously dense, which may obscure small masses

D: The breasts are extremely dense, which lowers the sensitivity of mammography

• About half of all women have dense breasts, and breast density can change throughout a woman’s lifetime.

• Having dense breasts is a risk factor for developing breast cancers (2).

• With denser breasts, it is harder to see cancer on a mammogram as cancers can “hide” behind breast tissue. Some radiologists compare it to looking for a polar bear in the snow, as both dense breast tissue and masses appear white or gray on mammograms.

• 3D mammograms (Digital Breast Tomosynthesis) are better at picking up subtle abnormalities in denser breasts than regular 2D mammograms. 3D mammography is more expensive than 2D, but it is becoming more widely used and covered by insurance companies.

• Breast ultrasound is often used following a diagnostic mammogram. One benefit of ultrasound is that masses appear as dark spots against grey/lighter breast tissue.

• Ultrasound, rather than mammography, is often used as a first-line diagnostic tool for younger women with breast complaints, as younger women tend to have denser breasts (3).

• In a majority of states (38 to be precise), the law states that following a mammogram, women with denser breasts must be informed in writing of the limitations of mammography in dense breast tissue. Legislation has now been passed to make this policy a requirement in all fifty states as of September 2024 (4).

Mammography Results

• Every time you get a screening or diagnostic mammogram, the radiologist assigns you a BI-RADS (Breast Imaging Reporting and Database System score) number from 0–6. You will be assigned a “0” if further work-up is required (5):

· BI-RADS 0: incomplete- need additional imaging evaluation (additional mammographic views or ultrasound)

· BI-RADS 1: negative- symmetrical and no masses, architectural distortion, or suspicious calcifications

· BI-RADS 2: benign- 0% probability of malignancy

· BI-RADS 3: probably benign- <2% probability of malignancy. Short-interval follow-up suggested

· BI-RADS 4: suspicious for malignancy- 2–94% probability of malignancy. Biopsy should be considered

· BI-RADS 5: highly suggestive of malignancy- >95% probability of malignancy. Appropriate action should be taken

· BI-RADS 6: known biopsy-proven malignancy

• For every 100 women who do a screening mammogram, only 10 will be called back for additional testing. Of those ten, only two will go on to require a biopsy (6).

Black Women and Breast Cancer (7)

• At least one study has shown that Black women are more prone to having dense breasts (8).

• Although Black women are diagnosed with breast cancer at a lower rate than White women, they are usually diagnosed later in the progression of the disease (the reasons for this deserve a separate article) and therefore have worse outcomes than White women (41% increased mortality rate).

• Black women are also more likely to be diagnosed with aggressive types of breast cancer that are difficult to treat and more likely to return.

• Sadly, Breast cancer has now become the leading cause of cancer deaths among Black women

Things to Keep in Mind

If you are anxiously awaiting callback appointments or the results of diagnostic mammograms, ultrasounds, MRIs, or biopsies, it’s important to maintain perspective by keeping the following information in mind:

• For every 1000 women who get a screening mammogram, 100 will be recalled for additional testing, and only 5 of the original 1000 will be diagnosed with cancer (9).

• When we think about masses and other abnormal findings on breasts, our minds automatically go to cancer. However, there are actually more benign than malignant conditions that cause masses and other abnormal findings in breast tissue, and some of these benign conditions may even require excision/lumpectomy due to causing pain/discomfort or being classified as high-risk. This information is worth remembering as we wait with bated breath for the call-back appointment or test results (10).

Important Screening Information

Want to screen for breast cancer but don’t have health coverage? The National Breast and Cervical Cancer Early Detection Program (NBCCCEDP) may be able to help. Click this link to see if you are eligible for free or low-cost screening in your area: https://www.cdc.gov/cancer/nbccedp/screenings.htm

Sources: 1. https://www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early-detection/mammograms/breast-density-and-your-mammogram-report.html 2. https://www.cancer.org/cancer/types/breast-cancer/risk-and-prevention/breast-cancer-risk-factors-you-cannot-change.html 3. https://www.ajronline.org/doi/10.2214/AJR.10.4396 https://www.hopkinsmedicine.org/imaging/provider-information/order-wisely/breast-ordering 4. https://www.areyoudense.org/news-events/map-all-pink/ https://www.fda.gov/news-events/press-announcements/fda-updates-mammography-regulations-require-reporting-breast-density-information-and-enhance 5. https://www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early-detection/mammograms/understanding-your-mammogram-report.html https://radiopaedia.org/articles/breast-imaging-reporting-and-data-system-bi-rads?lang=us 6. https://www.acr.org/-/media/ACR/Files/Breast-Imaging-Resources/MSLInfographic_highres.jpg 7. https://cancerblog.mayoclinic.org/2022/02/24/what-black-women-need-to-know-about-breast-cancer/ https://www.cancer.gov/news-events/cancer-currents-blog/2021/breast-cancer-risk-calculator-us-black-women 8. https://www.oncnursingnews.com/view/understanding-why-black-women-have-denser-breasts-may-help-target-those-with-highest-cancer-risk https://academic.oup.com/jnci/article/107/10/djv296/987327?login=false 9. https://www.docpanel.com/blog/post/understanding-your-mammogram-callback https://www.npr.org/sections/health-shots/2015/10/15/448888415/called-back-after-a-mammogram-doctors-are-trying-to-make-it-less-scary https://livehealthy.muhealth.org/stories/called-back-after-your-mammogram-answers-5-common-questions 10. https://www.cancer.org/cancer/types/breast-cancer/non-cancerous-breast-conditions.html