Marian Heesaker, RN, MS, MA, NP-C

Despite a modest reduction in incidence since 1999, breast cancer remains the second leading cause of cancer deaths in US women.¹ In the US alone, 50,430 cases of invasive breast cancer were reported in 2011 among women younger than 50, and 5,240 in this age-group died of the disease.² The full impact of breast cancer morbidity and mortality on families, relationships, careers, and unrealized human potential is difficult to measure.

Anticipatory guidance at each visit with premenopausal women older than 40 about the importance of regular mammography should result in higher rates of mammographic screening and early breast cancer detection.

CURRENT GUIDELINES
The American Cancer Society³ and the American College of Obstetricians and Gynecologists¹ recommend that women undergo annual mammograms and clinical breast exams after age 40. Of note, 70% of breast cancers in women younger than 50 are found by the women themselves.¹ Thus, encouraging women to become familiar with their breasts by regular self-breast examination increases the likelihood that they will notice changes warranting clinical follow-up.¹

In 2009, the US Preventive Services Task Force (USPSTF)⁴ issued a systematic evidence review update recommending biennial mammographic screening for women between ages 50 and 74 (with a revised recommendation against routine mammographic screening for women younger than 50^4-6). The USPSTF also cited insufficient evidence to advocate the clinical breast exam and did not recommend self-breast examination.^5,7-10

Given the lack of consensus, providers must rely on their clinical judgment to determine which guidelines to follow regarding the frequency at which to recommend breast cancer screening.

Encouraging Regular Screening
The key to early breast cancer detection is regularly scheduled screening.³ Screening improves interpretation through the availability of multiple films for comparison and the detection of smaller tumors earlier, when they are confined and successful treatment is statistically more likely. Sojourn time (the interval during which cancer screening can detect a tumor before it becomes symptomatic) demonstrates the worth of regular screening. For women between ages 40 and 49, the mean sojourn time is 2.0 to 2.4 years; in those ages 70 to 74, mean sojourn time is 4.0 to 4.1 years. Women with shorter sojourn times benefit from regular screening because their tumors can be detected earlier.¹

By minimizing the uncertainty and discomfort associated with mammography, clinicians can help increase patients’ adherence to a regular mammographic screening schedule. Effective strategies include informing patients in advance about what to expect, explaining the possibility of callbacks—and, in particular, scheduling mammograms at an optimal time in the patient’s menstrual cycle.

TIMING MAMMOGRAPHY IN PREMENOPAUSAL WOMEN
In women ages 40 to 49 who do not take oral contraceptives or hormone replacement therapy, mammography has lower sensitivity and specificity for breast cancer because breast density is greater.^11,12 For women in this age-group who undergo regular screening, sensitivity is enhanced when mammography is scheduled during weeks 1 and 2 of the menstrual cycle (ie, at onset of menses and during the 14 days that follow). In this follicular phase, breast density and parenchymal volume are decreased and breast tenderness is reduced. Thus, women are likely to find the procedure less uncomfortable at this time.

While increased screening sensitivity has been reported in women undergoing a first mammogram during the luteal phase (week 3 or 4),¹¹ breast density and parenchymal volume are also increased at this time,^13-15 with breasts usually more tender. If a woman finds her first mammogram painful, she may be less likely to schedule subsequent screenings in the future. Therefore, while the incidence of false-positives and -negatives may be higher for a first mammogram scheduled during the follicular phase, ensuring a positive first mammography experience may be the more important goal.

COMMON PATIENT CONCERNS
Pain
Women may need to be persuaded to return for routine mammography after a negative first experience. Pain secondary to the required compression force has led researchers to investigate whether patients should be allowed to control the compression force during mammography.¹⁶ However, clinical evidence indicates that a high-quality mammographic image for accurate interpretation requires compression of adequate force—controlled by a skilled technician.^12,17

Likewise, the manner in which the breast is placed and positioned on the platform contributes to the patient’s overall comfort or discomfort. Application of 4% lidocaine gel to the breast before mammography has been found significantly effective in reducing discomfort, compared with premedication with acetaminophen or ibuprofen.¹⁸ The use of a radiolucent breast cushion has also been shown to reduce the discomfort associated with a mammogram.¹⁹

The Clinical Experience
The skill and attitude of the mammography technologist are important factors in the impression, positive or negative, with which the patient leaves the imaging center. Personal attention to the patient, an unhurried demeanor, a pleasant environment, respect for the patient’s comfort and privacy, and a compassionate and skilled staff are all important. Factors from the receptionist’s greeting to how smoothly the procedure is carried out play a role in whether the patient will be willing to return.²⁰

Callbacks and Scheduling
On first mammogram, 14% of women have a false-positive result, as do 8% of women who undergo screenings regularly.¹¹ Reducing the time between initial and repeat exams can alleviate the anxiety associated with a positive result, whether false or not. Offering mammography appointments outside the standard Monday-through-Friday, 8-to-5 schedule can help reduce the wait time. It may also minimize the inconvenience of scheduling an appointment around multiple family and work obligations.²⁰

IMPROVING PATIENT EXPERIENCES AND OUTCOMES
Providing consistent, accurate written or verbal information before mammography helps ensure timely, effective mammography.¹² Use of an educational handout can eliminate the possibility that important information will be overlooked and can contribute to a positive overall impression of the screening experience.

An important element is to advise the patient of the best time in her menstrual cycle to schedule her exam.

Key Points for the Provider
•

Encourage women to familiarize themselves with their breasts.¹

•

Advise women to undergo a clinical breast exam annually after age 40.^1,3

•

Encourage patients to schedule mammograms (especially a patient’s first mammogram) during week 1 or 2 of the menstrual cycle.^13-15

•

Provide the patient with written or verbal information in advance about the procedure and what to expect—including the possibility of a callback.¹²

•

If rescreening is deemed necessary, make a personal phone call to notify the patient.

•

Work with your imaging center to offer appointments outside standard business hours and minimize wait time before repeat screening (if needed).²⁰

CONCLUSION
Putting the right information in the hands of the patient (particularly the premenopausal woman in her 40s) is likely to result in an accurate mammographic screening with minimal discomfort. This will help reduce the incidence of false-positive results and remove as many barriers to screening compliance as possible.

REFERENCES
1. American College of Obstetricians–Gynecologists. Practice Bulletin No. 122: Breast cancer screening. Obstet Gynecol. 2011;118(2 pt 1):372-382.

2. American Cancer Society. Breast Cancer Facts & Figures 2011-2012. www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-030975.pdf. Accessed September 20, 2012.

3. American Cancer Society Guidelines for the Early Detection of Cancer. Breast cancer. www

.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer. Accessed September 20, 2012.

4. US Preventive Services Task Force. Screening for breast cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151(10):716-726.

5. Nelson HD, Tyne K, Naik A, et al. Screening for breast cancer: an update for the US Preventive Services Task Force. Ann Intern Med. 2009; 151(10):727-737.

6. Moss SM, Cuckle H, Evans A, et al. Effect of mammographic screening from age 40 years on breast cancer mortality at 10 years’ follow-up: a randomised controlled trial. Lancet. 2006;368 (9552):2053-2060.

7. Miller AB, To T, Baines CJ, Wall C. Canadian National Breast Screening Study-2: 13-year results of a randomized trial in women aged 50-59 years. J Natl Cancer Inst. 2000;92(18):1490–9.

8. Thomas DB, Gao DL, Ray RM, et al. Randomized trial of breast self-examination in Shanghai: final results. J Natl Cancer Inst. 2002;94 (19):1445-1457.

9. Semiglazov VF, Manikhas AG, Moiseenko VM, et al. Results of a prospective randomized investigation [Russia (St.Petersburg)/WHO] to evaluate the significance of self-examination for the early detection of breast cancer [in Russian]. Vopr Onkol. 2003;49(4):434-441.

10. Tu SP, Reisch LM, Taplin SH, et al. Breast self-examination: self-reported frequency, quality, and associated outcomes. J Cancer Educ. 2006;21(3): 175-181.

11. Miglioretti DL, Walker R, Weaver DL, ET AL. Accuracy of screening mammography varies by week of menstrual cycle. Radiology. 2011; 258(2):372-379.

12. Miller D, Livingstone V, Herbison P. Interventions for relieving the pain and discomfort of screening mammography. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD002942.

13. Morrow M, Chatterton RT Jr, Rademaker AW, et al. A prospective study of variability in mammographic density during the menstrual cycle. Breast Cancer Res Treat. 2010;121(3):565-574.

14. White E, Velentgas P, Mandelson MT, et al. Variation in mammographic breast density by time in menstrual cycle among women aged 40-49 years. J Natl Cancer Inst. 1998;90(12): 906-910.

15. Fowler BA, Casey CE, Cameron GG, et al. Cyclic changes in composition and volume of the breast during the menstrual cycle, measured by magnetic resonance imaging. Br J Obstet Gynaecol. 1990;97(7):595-602.

16. Kornguth PJ, Rimer BK, Conaway MR, et al. Impact of patient-controlled compression on the mammography experience. Radiology. 1993; 186(1):99-102.

17. Poulos A, McLean D, Rickard M, Heard R. Breast compression in mammography: how much is enough? Australas Radiol. 2003;47 (2):121-126.

18. Lambertz CK, Johnson CJ, Montgomery PG, Maxwell JR. Premedication to reduce discomfort during screening mammography. Radiology. 2008;248(3):765-772.

19. Markle L, Roux S, Sayre JW. Reduction of discomfort during mammography utilizing a radiolucent cushioning pad. Breast J. 2004;10 (4):345-349.

20. Engelman KK, Cizik AM, Ellerbeck EF. Women’s satisfaction with their mammography experience: results of a qualitative study. Women Health. 2005;42(4):17-35.

Despite a modest reduction in incidence since 1999, breast cancer remains the second leading cause of cancer deaths in US women.¹ In the US alone, 50,430 cases of invasive breast cancer were reported in 2011 among women younger than 50, and 5,240 in this age-group died of the disease.² The full impact of breast cancer morbidity and mortality on families, relationships, careers, and unrealized human potential is difficult to measure.

Anticipatory guidance at each visit with premenopausal women older than 40 about the importance of regular mammography should result in higher rates of mammographic screening and early breast cancer detection.

CURRENT GUIDELINES
The American Cancer Society³ and the American College of Obstetricians and Gynecologists¹ recommend that women undergo annual mammograms and clinical breast exams after age 40. Of note, 70% of breast cancers in women younger than 50 are found by the women themselves.¹ Thus, encouraging women to become familiar with their breasts by regular self-breast examination increases the likelihood that they will notice changes warranting clinical follow-up.¹

In 2009, the US Preventive Services Task Force (USPSTF)⁴ issued a systematic evidence review update recommending biennial mammographic screening for women between ages 50 and 74 (with a revised recommendation against routine mammographic screening for women younger than 50^4-6). The USPSTF also cited insufficient evidence to advocate the clinical breast exam and did not recommend self-breast examination.^5,7-10

Given the lack of consensus, providers must rely on their clinical judgment to determine which guidelines to follow regarding the frequency at which to recommend breast cancer screening.

Encouraging Regular Screening
The key to early breast cancer detection is regularly scheduled screening.³ Screening improves interpretation through the availability of multiple films for comparison and the detection of smaller tumors earlier, when they are confined and successful treatment is statistically more likely. Sojourn time (the interval during which cancer screening can detect a tumor before it becomes symptomatic) demonstrates the worth of regular screening. For women between ages 40 and 49, the mean sojourn time is 2.0 to 2.4 years; in those ages 70 to 74, mean sojourn time is 4.0 to 4.1 years. Women with shorter sojourn times benefit from regular screening because their tumors can be detected earlier.¹

By minimizing the uncertainty and discomfort associated with mammography, clinicians can help increase patients’ adherence to a regular mammographic screening schedule. Effective strategies include informing patients in advance about what to expect, explaining the possibility of callbacks—and, in particular, scheduling mammograms at an optimal time in the patient’s menstrual cycle.

TIMING MAMMOGRAPHY IN PREMENOPAUSAL WOMEN
In women ages 40 to 49 who do not take oral contraceptives or hormone replacement therapy, mammography has lower sensitivity and specificity for breast cancer because breast density is greater.^11,12 For women in this age-group who undergo regular screening, sensitivity is enhanced when mammography is scheduled during weeks 1 and 2 of the menstrual cycle (ie, at onset of menses and during the 14 days that follow). In this follicular phase, breast density and parenchymal volume are decreased and breast tenderness is reduced. Thus, women are likely to find the procedure less uncomfortable at this time.

While increased screening sensitivity has been reported in women undergoing a first mammogram during the luteal phase (week 3 or 4),¹¹ breast density and parenchymal volume are also increased at this time,^13-15 with breasts usually more tender. If a woman finds her first mammogram painful, she may be less likely to schedule subsequent screenings in the future. Therefore, while the incidence of false-positives and -negatives may be higher for a first mammogram scheduled during the follicular phase, ensuring a positive first mammography experience may be the more important goal.

COMMON PATIENT CONCERNS
Pain
Women may need to be persuaded to return for routine mammography after a negative first experience. Pain secondary to the required compression force has led researchers to investigate whether patients should be allowed to control the compression force during mammography.¹⁶ However, clinical evidence indicates that a high-quality mammographic image for accurate interpretation requires compression of adequate force—controlled by a skilled technician.^12,17

Likewise, the manner in which the breast is placed and positioned on the platform contributes to the patient’s overall comfort or discomfort. Application of 4% lidocaine gel to the breast before mammography has been found significantly effective in reducing discomfort, compared with premedication with acetaminophen or ibuprofen.¹⁸ The use of a radiolucent breast cushion has also been shown to reduce the discomfort associated with a mammogram.¹⁹

The Clinical Experience
The skill and attitude of the mammography technologist are important factors in the impression, positive or negative, with which the patient leaves the imaging center. Personal attention to the patient, an unhurried demeanor, a pleasant environment, respect for the patient’s comfort and privacy, and a compassionate and skilled staff are all important. Factors from the receptionist’s greeting to how smoothly the procedure is carried out play a role in whether the patient will be willing to return.²⁰

Callbacks and Scheduling
On first mammogram, 14% of women have a false-positive result, as do 8% of women who undergo screenings regularly.¹¹ Reducing the time between initial and repeat exams can alleviate the anxiety associated with a positive result, whether false or not. Offering mammography appointments outside the standard Monday-through-Friday, 8-to-5 schedule can help reduce the wait time. It may also minimize the inconvenience of scheduling an appointment around multiple family and work obligations.²⁰

IMPROVING PATIENT EXPERIENCES AND OUTCOMES
Providing consistent, accurate written or verbal information before mammography helps ensure timely, effective mammography.¹² Use of an educational handout can eliminate the possibility that important information will be overlooked and can contribute to a positive overall impression of the screening experience.

An important element is to advise the patient of the best time in her menstrual cycle to schedule her exam.

Key Points for the Provider
•

Encourage women to familiarize themselves with their breasts.¹

•

Advise women to undergo a clinical breast exam annually after age 40.^1,3

•

Encourage patients to schedule mammograms (especially a patient’s first mammogram) during week 1 or 2 of the menstrual cycle.^13-15

•

Provide the patient with written or verbal information in advance about the procedure and what to expect—including the possibility of a callback.¹²

•

If rescreening is deemed necessary, make a personal phone call to notify the patient.

•

Work with your imaging center to offer appointments outside standard business hours and minimize wait time before repeat screening (if needed).²⁰

CONCLUSION
Putting the right information in the hands of the patient (particularly the premenopausal woman in her 40s) is likely to result in an accurate mammographic screening with minimal discomfort. This will help reduce the incidence of false-positive results and remove as many barriers to screening compliance as possible.

REFERENCES
1. American College of Obstetricians–Gynecologists. Practice Bulletin No. 122: Breast cancer screening. Obstet Gynecol. 2011;118(2 pt 1):372-382.

2. American Cancer Society. Breast Cancer Facts & Figures 2011-2012. www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-030975.pdf. Accessed September 20, 2012.

3. American Cancer Society Guidelines for the Early Detection of Cancer. Breast cancer. www

.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer. Accessed September 20, 2012.

4. US Preventive Services Task Force. Screening for breast cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151(10):716-726.

5. Nelson HD, Tyne K, Naik A, et al. Screening for breast cancer: an update for the US Preventive Services Task Force. Ann Intern Med. 2009; 151(10):727-737.

6. Moss SM, Cuckle H, Evans A, et al. Effect of mammographic screening from age 40 years on breast cancer mortality at 10 years’ follow-up: a randomised controlled trial. Lancet. 2006;368 (9552):2053-2060.

7. Miller AB, To T, Baines CJ, Wall C. Canadian National Breast Screening Study-2: 13-year results of a randomized trial in women aged 50-59 years. J Natl Cancer Inst. 2000;92(18):1490–9.

8. Thomas DB, Gao DL, Ray RM, et al. Randomized trial of breast self-examination in Shanghai: final results. J Natl Cancer Inst. 2002;94 (19):1445-1457.

9. Semiglazov VF, Manikhas AG, Moiseenko VM, et al. Results of a prospective randomized investigation [Russia (St.Petersburg)/WHO] to evaluate the significance of self-examination for the early detection of breast cancer [in Russian]. Vopr Onkol. 2003;49(4):434-441.

10. Tu SP, Reisch LM, Taplin SH, et al. Breast self-examination: self-reported frequency, quality, and associated outcomes. J Cancer Educ. 2006;21(3): 175-181.

11. Miglioretti DL, Walker R, Weaver DL, ET AL. Accuracy of screening mammography varies by week of menstrual cycle. Radiology. 2011; 258(2):372-379.

12. Miller D, Livingstone V, Herbison P. Interventions for relieving the pain and discomfort of screening mammography. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD002942.

13. Morrow M, Chatterton RT Jr, Rademaker AW, et al. A prospective study of variability in mammographic density during the menstrual cycle. Breast Cancer Res Treat. 2010;121(3):565-574.

14. White E, Velentgas P, Mandelson MT, et al. Variation in mammographic breast density by time in menstrual cycle among women aged 40-49 years. J Natl Cancer Inst. 1998;90(12): 906-910.

15. Fowler BA, Casey CE, Cameron GG, et al. Cyclic changes in composition and volume of the breast during the menstrual cycle, measured by magnetic resonance imaging. Br J Obstet Gynaecol. 1990;97(7):595-602.

16. Kornguth PJ, Rimer BK, Conaway MR, et al. Impact of patient-controlled compression on the mammography experience. Radiology. 1993; 186(1):99-102.

17. Poulos A, McLean D, Rickard M, Heard R. Breast compression in mammography: how much is enough? Australas Radiol. 2003;47 (2):121-126.

18. Lambertz CK, Johnson CJ, Montgomery PG, Maxwell JR. Premedication to reduce discomfort during screening mammography. Radiology. 2008;248(3):765-772.

19. Markle L, Roux S, Sayre JW. Reduction of discomfort during mammography utilizing a radiolucent cushioning pad. Breast J. 2004;10 (4):345-349.

20. Engelman KK, Cizik AM, Ellerbeck EF. Women’s satisfaction with their mammography experience: results of a qualitative study. Women Health. 2005;42(4):17-35.

Despite a modest reduction in incidence since 1999, breast cancer remains the second leading cause of cancer deaths in US women.¹ In the US alone, 50,430 cases of invasive breast cancer were reported in 2011 among women younger than 50, and 5,240 in this age-group died of the disease.² The full impact of breast cancer morbidity and mortality on families, relationships, careers, and unrealized human potential is difficult to measure.

Anticipatory guidance at each visit with premenopausal women older than 40 about the importance of regular mammography should result in higher rates of mammographic screening and early breast cancer detection.

CURRENT GUIDELINES
The American Cancer Society³ and the American College of Obstetricians and Gynecologists¹ recommend that women undergo annual mammograms and clinical breast exams after age 40. Of note, 70% of breast cancers in women younger than 50 are found by the women themselves.¹ Thus, encouraging women to become familiar with their breasts by regular self-breast examination increases the likelihood that they will notice changes warranting clinical follow-up.¹

In 2009, the US Preventive Services Task Force (USPSTF)⁴ issued a systematic evidence review update recommending biennial mammographic screening for women between ages 50 and 74 (with a revised recommendation against routine mammographic screening for women younger than 50^4-6). The USPSTF also cited insufficient evidence to advocate the clinical breast exam and did not recommend self-breast examination.^5,7-10

Given the lack of consensus, providers must rely on their clinical judgment to determine which guidelines to follow regarding the frequency at which to recommend breast cancer screening.

Encouraging Regular Screening
The key to early breast cancer detection is regularly scheduled screening.³ Screening improves interpretation through the availability of multiple films for comparison and the detection of smaller tumors earlier, when they are confined and successful treatment is statistically more likely. Sojourn time (the interval during which cancer screening can detect a tumor before it becomes symptomatic) demonstrates the worth of regular screening. For women between ages 40 and 49, the mean sojourn time is 2.0 to 2.4 years; in those ages 70 to 74, mean sojourn time is 4.0 to 4.1 years. Women with shorter sojourn times benefit from regular screening because their tumors can be detected earlier.¹

By minimizing the uncertainty and discomfort associated with mammography, clinicians can help increase patients’ adherence to a regular mammographic screening schedule. Effective strategies include informing patients in advance about what to expect, explaining the possibility of callbacks—and, in particular, scheduling mammograms at an optimal time in the patient’s menstrual cycle.

TIMING MAMMOGRAPHY IN PREMENOPAUSAL WOMEN
In women ages 40 to 49 who do not take oral contraceptives or hormone replacement therapy, mammography has lower sensitivity and specificity for breast cancer because breast density is greater.^11,12 For women in this age-group who undergo regular screening, sensitivity is enhanced when mammography is scheduled during weeks 1 and 2 of the menstrual cycle (ie, at onset of menses and during the 14 days that follow). In this follicular phase, breast density and parenchymal volume are decreased and breast tenderness is reduced. Thus, women are likely to find the procedure less uncomfortable at this time.

While increased screening sensitivity has been reported in women undergoing a first mammogram during the luteal phase (week 3 or 4),¹¹ breast density and parenchymal volume are also increased at this time,^13-15 with breasts usually more tender. If a woman finds her first mammogram painful, she may be less likely to schedule subsequent screenings in the future. Therefore, while the incidence of false-positives and -negatives may be higher for a first mammogram scheduled during the follicular phase, ensuring a positive first mammography experience may be the more important goal.

COMMON PATIENT CONCERNS
Pain
Women may need to be persuaded to return for routine mammography after a negative first experience. Pain secondary to the required compression force has led researchers to investigate whether patients should be allowed to control the compression force during mammography.¹⁶ However, clinical evidence indicates that a high-quality mammographic image for accurate interpretation requires compression of adequate force—controlled by a skilled technician.^12,17

Likewise, the manner in which the breast is placed and positioned on the platform contributes to the patient’s overall comfort or discomfort. Application of 4% lidocaine gel to the breast before mammography has been found significantly effective in reducing discomfort, compared with premedication with acetaminophen or ibuprofen.¹⁸ The use of a radiolucent breast cushion has also been shown to reduce the discomfort associated with a mammogram.¹⁹

The Clinical Experience
The skill and attitude of the mammography technologist are important factors in the impression, positive or negative, with which the patient leaves the imaging center. Personal attention to the patient, an unhurried demeanor, a pleasant environment, respect for the patient’s comfort and privacy, and a compassionate and skilled staff are all important. Factors from the receptionist’s greeting to how smoothly the procedure is carried out play a role in whether the patient will be willing to return.²⁰

Callbacks and Scheduling
On first mammogram, 14% of women have a false-positive result, as do 8% of women who undergo screenings regularly.¹¹ Reducing the time between initial and repeat exams can alleviate the anxiety associated with a positive result, whether false or not. Offering mammography appointments outside the standard Monday-through-Friday, 8-to-5 schedule can help reduce the wait time. It may also minimize the inconvenience of scheduling an appointment around multiple family and work obligations.²⁰

IMPROVING PATIENT EXPERIENCES AND OUTCOMES
Providing consistent, accurate written or verbal information before mammography helps ensure timely, effective mammography.¹² Use of an educational handout can eliminate the possibility that important information will be overlooked and can contribute to a positive overall impression of the screening experience.

An important element is to advise the patient of the best time in her menstrual cycle to schedule her exam.

Key Points for the Provider
•

Encourage women to familiarize themselves with their breasts.¹

•

Advise women to undergo a clinical breast exam annually after age 40.^1,3

•

Encourage patients to schedule mammograms (especially a patient’s first mammogram) during week 1 or 2 of the menstrual cycle.^13-15

•

Provide the patient with written or verbal information in advance about the procedure and what to expect—including the possibility of a callback.¹²

•

If rescreening is deemed necessary, make a personal phone call to notify the patient.

•

Work with your imaging center to offer appointments outside standard business hours and minimize wait time before repeat screening (if needed).²⁰

CONCLUSION
Putting the right information in the hands of the patient (particularly the premenopausal woman in her 40s) is likely to result in an accurate mammographic screening with minimal discomfort. This will help reduce the incidence of false-positive results and remove as many barriers to screening compliance as possible.

REFERENCES
1. American College of Obstetricians–Gynecologists. Practice Bulletin No. 122: Breast cancer screening. Obstet Gynecol. 2011;118(2 pt 1):372-382.

2. American Cancer Society. Breast Cancer Facts & Figures 2011-2012. www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-030975.pdf. Accessed September 20, 2012.

3. American Cancer Society Guidelines for the Early Detection of Cancer. Breast cancer. www

.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer. Accessed September 20, 2012.

4. US Preventive Services Task Force. Screening for breast cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151(10):716-726.

5. Nelson HD, Tyne K, Naik A, et al. Screening for breast cancer: an update for the US Preventive Services Task Force. Ann Intern Med. 2009; 151(10):727-737.

6. Moss SM, Cuckle H, Evans A, et al. Effect of mammographic screening from age 40 years on breast cancer mortality at 10 years’ follow-up: a randomised controlled trial. Lancet. 2006;368 (9552):2053-2060.

7. Miller AB, To T, Baines CJ, Wall C. Canadian National Breast Screening Study-2: 13-year results of a randomized trial in women aged 50-59 years. J Natl Cancer Inst. 2000;92(18):1490–9.

8. Thomas DB, Gao DL, Ray RM, et al. Randomized trial of breast self-examination in Shanghai: final results. J Natl Cancer Inst. 2002;94 (19):1445-1457.

9. Semiglazov VF, Manikhas AG, Moiseenko VM, et al. Results of a prospective randomized investigation [Russia (St.Petersburg)/WHO] to evaluate the significance of self-examination for the early detection of breast cancer [in Russian]. Vopr Onkol. 2003;49(4):434-441.

10. Tu SP, Reisch LM, Taplin SH, et al. Breast self-examination: self-reported frequency, quality, and associated outcomes. J Cancer Educ. 2006;21(3): 175-181.

11. Miglioretti DL, Walker R, Weaver DL, ET AL. Accuracy of screening mammography varies by week of menstrual cycle. Radiology. 2011; 258(2):372-379.

12. Miller D, Livingstone V, Herbison P. Interventions for relieving the pain and discomfort of screening mammography. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD002942.

13. Morrow M, Chatterton RT Jr, Rademaker AW, et al. A prospective study of variability in mammographic density during the menstrual cycle. Breast Cancer Res Treat. 2010;121(3):565-574.

14. White E, Velentgas P, Mandelson MT, et al. Variation in mammographic breast density by time in menstrual cycle among women aged 40-49 years. J Natl Cancer Inst. 1998;90(12): 906-910.

15. Fowler BA, Casey CE, Cameron GG, et al. Cyclic changes in composition and volume of the breast during the menstrual cycle, measured by magnetic resonance imaging. Br J Obstet Gynaecol. 1990;97(7):595-602.

16. Kornguth PJ, Rimer BK, Conaway MR, et al. Impact of patient-controlled compression on the mammography experience. Radiology. 1993; 186(1):99-102.

17. Poulos A, McLean D, Rickard M, Heard R. Breast compression in mammography: how much is enough? Australas Radiol. 2003;47 (2):121-126.

18. Lambertz CK, Johnson CJ, Montgomery PG, Maxwell JR. Premedication to reduce discomfort during screening mammography. Radiology. 2008;248(3):765-772.

19. Markle L, Roux S, Sayre JW. Reduction of discomfort during mammography utilizing a radiolucent cushioning pad. Breast J. 2004;10 (4):345-349.

20. Engelman KK, Cizik AM, Ellerbeck EF. Women’s satisfaction with their mammography experience: results of a qualitative study. Women Health. 2005;42(4):17-35.