Your 1-2-3 Guide to Healthy Breasts

When it's time for your mammogram, you want it done right. Use this sleep-easier guide to get custom care.

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We know: It's no picnic to go to a center or clinic, stand in a room half-naked, and have your breasts smooshed between two cold plates. If you're gonna go through all that, you want to come out with peace of mind, knowing you've had the best possible breast cancer screening (and please, no do-overs or extra trips). Once you and your doc have decided when you should get a mammogram, you need to bring up the three issues on these pages. Don't just take the prescription and run. Use this guide to get the personalized plan you deserve.

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1. Ask the Density Question

Everyone's breasts, no matter their shape or size, contain a combination of tissue—some of it's fatty (that's actually good when it comes to mammograms), and the rest is fibrous and glandular tissue. The less fat you have there, the denser your breasts are.

The trouble with dense breasts is that they raise your risk of cancer—in fact, women with extremely dense breasts have as much as double the risk of developing breast cancer as those with average density. Additionally, they make it harder for doctors to catch problems on a standard mammogram. Dense tissue appears white on X-rays—and so does cancer. "It's like finding a snowball in a snowstorm," says Kathy Schilling, M.D., medical director of Christine E. Lynn Women's Health & Wellness Institute at Boca Raton Regional Hospital.

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Dense breasts turn out to be common—some estimates say about half of women under the age of 50 and about a third of women older than that have them. Do you know where you fall on the density scale? It's not surprising if you don't. As of this year, 24 states have passed laws requiring women to be informed if their breasts are dense. So in more than 50% of states, you don't need to be told. Lawmakers on a national level have turned their attention to the issue because women weren't getting this vital info; a group of senators recently introduced a bill to Congress that would make a similar law universal. But it doesn't take a federal mandate for you to be able to find out your density. If you've already had a mammogram, your doctor should have the radiologist's report and be able to tell you right away.

Dense breasts make it harder for doctors to catch problems on a standard mammogram.
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Then what? Stick with us. When women with dense breasts get additional screenings, such as a breast ultrasound, more problems are detected that their mammogram didn't show. So every woman with dense breasts needs more than just a mammogram, right?

Surprisingly, many top experts don't think so. Some Harvard and Beth Israel Deaconess Medical Center docs recently penned an editorial in the New England Journal of Medicine detailing why. These extra screenings may catch more cancers, but they also create as many as five times more false alarms: suspicious results that turn out to be harmless after a biopsy (and a lot of anxiety). "Just because you can have a test doesn't mean it's in your best interest to get it," says Joann Elmore, M.D., a professor of medicine at the University of Washington School of Medicine and an investigator with the Fred Hutchinson Cancer Research Center. "People think, I need to get an ultrasound, I need to get an MRI. But mammography is the most well-studied of any screening tool." And it's still the only type of scan that's been shown to reduce the rate of breast cancer deaths. Knowledge is power, adds Dr. Oz, "but we don't have to act on all we know. Deciding not to move forward in certain situations is also a valid decision."

That's why doctors are cautious about supporting laws that stipulate extra testing for women with dense breasts. "This is a place where legislation has really gotten ahead of the science," says Therese Bevers, M.D., medical director of the cancer prevention center at MD Anderson Cancer Center in Houston. While extra screening can catch more cancers in women with dense breasts, there's no evidence yet that it actually saves lives.

If you have a strong family history of breast or ovarian cancer, consider scheduling a sit-down with a genetic counselor.
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A recent big study by the National Cancer Institute suggests a middle ground. Breast density shouldn't be the only thing that determines additional screening, says researcher and breast density expert Karla Kerlikowske, M.D., a professor of medicine, epidemiology, and biostatistics at the University of California, San Francisco. You and your doctor need to look at everything that could bump up your risk of getting breast cancer—that includes factors like your age, race, family history of breast cancer, and breast biopsy history. Then you consider your density and your risk together to come up with an individual plan. (You never get to skip the mammogram, by the way. Additional screenings are just that—extras, not substitutes.) That brings us to step two.

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2. Add up Risk

If you have one or more close relatives with breast or ovarian cancer, then you and your doctor should do some calculations to figure out whether you need extra screening. You'll want to determine your lifetime risk of breast cancer, says the American Cancer Society (ACS). If it's above a certain level, the ACS recommends that you get an MRI along with a mammogram. (It also recommends one if you have a first-degree relative with the "breast cancer gene," which is the BRCA1 or BRCA2 mutation.) If your risk is a little bit below that and you have dense breasts, you may also need additional scans.

So how do you figure out your risk? The best tools are special scientific calculators that you go through with your doctor. (They're much more detailed and time-consuming than the short ones you can find online.)

Your physician may not have time to work through this with you. Think you have a strong family history? Consider a sit-down with a genetic counselor. "If your doctor isn't skilled in doing lifetime risk assessments, get a referral to someone who is," advises Debbie Saslow, Ph.D., director of breast and gynecologic cancer at the American Cancer Society.

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3. Be Smart about the Tests You Get

Your doctor should help walk you through the pros and cons of different tests. Whichever ones you decide to get, you'll want to know a little about them—it makes the whole process less nerve-jangling.

You may not always need every test, but you do need to weigh the pluses and minuses of each one.


Uses sound waves to produce an image of the breast. (It's the same technology used for sonograms.)

Who should get it: It's not always a must-do for women with dense breasts. It may be best reserved for those with dense breasts and other risk factors, says Kerlikowske. (Breast cancer organizations haven't put out guidelines yet.) It finds slightly more cancers (4.2 more cases per 1,000 women screened) in women with dense breasts when combined with mammography than mammograms do on their own.

Be prepared: It's associated with a lot of false positives, which can make it more likely you'll be sent for a biopsy. What to keep in mind: Of all of the women who get biopsies, the majority find out they don't have cancer.

Breast MRI

Magnets and radio waves create detailed images of "slices" of the breast.

Who should get it: According to the American Cancer Society, women who have a high lifetime risk based on family history, have a BRCA gene mutation or a first-degree family member who has it, received chest radiation therapy before age 30, or have certain rare genetic conditions. Some radiologists routinely use it in women with very dense breasts.

Be prepared: It's more sensitive than mammograms and ultrasounds, but it's also pricey and more of a hassle: You're facedown in the machine's tube for up to an hour. It turns up more false positives than mammography.

3-D Mammography

A new type of X-ray that captures many images of the breast and combines them into a 3-D picture, which helps catch more cancers.

Who should get it: If a center offers it and insurance pays, some doctors think everyone should get it, especially those who have dense breasts.

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Be prepared: Some docs think these are so much better at reducing unnecessary follow-up scans and biopsies that they could replace traditional mammography in the future. But that's still pretty far off. Right now, 3-D mammograms are mostly offered in major medical or research institutions, meaning you'd likely have to travel to find a place that does them. And if your insurance doesn't pay for this particular technology (many don't), you could be on the hook for about $50–$100.

Insider Secrets to Make Your Mammo Easier

We got these from the technicians who do dozens of scans a day. So helpful.

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  • Forget the horror stories. Everyone's pain tolerance is different, so whatever you've heard about these scans hurting probably won't be the same for you. In fact, less than 35% of women say they're painful.
  • Wear a two-piece outfit. You'll only have to take the top off, so you'll feel less exposed.
  • Wait until your period is over. Your breasts will be less sensitive when menstrual hormones aren't puffing you up.
  • Speak up if you're truly uncomfortable. Your skin might be pinched in a place the tech can't see, and she can try repositioning you. Or she might let you adjust things yourself. One study saw that women who did this felt less pain, and guess what? The scans were just as good.
  • Get your mind out of there. The more you relax, the better pictures the tech can get. "When your shoulders and chest are really tight, we can't get your breast tissue to come forward," explains Karen Dumont, a breast technologist at Massachusetts General Hospital. The old "imagine yourself at the beach" trick truly does help ease stress. Also, relax your face and fingers—it makes your whole body less tense.
The more you relax, the better pictures the tech can get and the faster you'll be out of there.

Joan Lunden Says: Know Your Breasts!

In her new memoir, Had I Known, former Good Morning America cohost Joan Lunden candidly details her successful battle with breast cancer. Lunden has dense breasts and, in 2014, her cancer was discovered after she asked her doctor for an ultrasound along with her mammogram. Here, she shares "the good, the bad, and the bald, ugly truth" of her journey—and what she hopes women can learn from her experience.

The Good Life: What made you ask for an ultrasound?

Joan Lunden: It was dumb luck. I got sent on a story to interview Dr. Susan Love about mammograms. When the tape wasn't rolling, we got into a kind of chitchatty conversation and she said, "You do get your mammograms, right, Joan? Regularly?" I said, "Yes, yes, yes, I get them, but they're so nerve-racking because every time I go, they always call me in again and again, and you freak out when they do that. I would ask if they saw something, and they'd always say the same thing: "No, it's just that we can't see anything. You have such fibrous, dense breast tissue." With that, Dr. Love looked at me and said, "Oh, well, if you have really fibrous, dense breast tissue, you should see about getting an ultrasound." It wasn't the first time I'd heard this. When I was interviewing Dr. Judith Reichman, she said the same thing. I didn't do anything when I heard it the first time. But the second time, I asked my doctor for a prescription for an ultrasound along with my mammogram. And when I got it—barely 10 minutes after a "clean" mammogram—it showed the cancer.

TGL: How can women get what they need?

JL: You have to know whether or not you have dense breasts. Call your physician and look carefully at your reports. I got copies of 15 reports that were sent to my physician, and every one of those reports starts out with the "happy gram." It says, "From what we could see, your mammogram was normal." The operative phrase there that should perk up our ears is, "From what we can see." Down at the bottom of those reports it says, "This woman has very dense breast tissue, which could mask breast cancer, and an ancillary test is most likely recommended." Let's be honest, once you read the first paragraph that says it's normal, you stop reading. Don't do that before you know your density.

TGL: So what do you want our readers to know?

JL: Find out what's really going on in your body. I want to inspire women to go and get the right scans. So many women haven't had them in a while for no really good reason—just because they had 87 other things on their to-do list. Be your own best health advocate.

This story originally appeared in the October 2015 issue of Dr. Oz The Good Life.

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