I have been a breast cancer surgeon at Baystate Health for 16 years. Providers like me are often asked during Breast Cancer Awareness Month about advances in prevention and treatment for a disease which affects one in eight women over their lifetimes.

One of the challenges in mammography-based screening guidelines for breast cancer is that the recommendations start at age 40. Mammography is less effective in young women due to increased breast density in young patients. Unfortunately, my colleagues and I see patients with breast cancer in the under-40 age group. Although this represents a small portion of all breast cancer patients (approximately seven percent of all breast cancers), these patients often present with advanced-stage disease due to the lack of imaging-based screening, which means that the cancer is detected by the patient herself when she feels a mass.

For women under the age of 40, “screening” relies on a clinical breast exam by a primary care provider or OB/GYN, as well as self-breast exam. The concept of the self-breast exam has been controversial in the over-40 population due to the proven effectiveness and improved access to screening mammography. For this reason, it is no longer recommended by the American Cancer Society (ACS) because of the lack of data showing a clear benefit in the over-40 population who undergo mammograms.

Women under the age of 40 should be encouraged to develop a routine schedule (once a month) to examine their breasts. However, if a mass is detected that persists as the woman goes through her monthly hormonal cycle, evaluation should be undertaken.

There are women under the age of 40 who will qualify for early screening with imaging. Examples include patients with a genetic mutation predisposing them to breast cancer such as the BRCA mutation, patients with a strong family history for breast cancer without a genetic mutation, or patients who received chest radiation while being treated for Hodgkin’s lymphoma. For these patients, screening will be in the form of a breast MRI, as mammography is less effective in young women due to the density of their breasts.

I see breast cancer patients who have found their own cancers, and this is typically the case for women under 40 who are generally not screened. Older patients also may present having found their own cancer between screening mammograms (known as interval cancers).

Unfortunately, the national societies differ in their recommendations as to when women of average risk should begin having mammograms. This makes it very difficult for patients to decide when they want to start having a mammogram. Currently, the ACS recommends average-risk women begin yearly mammograms at age 45, while the United States Preventative Services Task Force (USPTF) recommends starting mammograms every two years at age 50.

At Baystate Health, we recommend that average-risk women absolutely start their mammograms no later than age 50 and to have them no further out then every two years. Women who have a higher than average risk should consider starting yearly mammograms at age 40.

Women should talk with their primary care provider about their level of risk for breast cancer. If they are at average risk, they should learn about the pros and cons of mammograms to determine whether they want to have a mammogram starting at age 40 or wait until they are 50. The issue is that women in their 40s have breasts that are denser than women in their 50s. This increased density may lead to abnormal readings that require additional imaging and potentially a biopsy for what may end up being something that is not cancer, which is known as a false positive.

It is important for patients to discuss any family history of any type of cancer with their provider. Much more is known today about genes linked to cancer and thus how one type of cancer can be a risk for another. Collecting a family history is no longer just about breast cancer; many different types of cancer may be linked.

The Baystate Health Family Cancer Genetics program has streamlined the process so if a patient wants to be evaluated, they can contact the program and send their family history paperwork in to be assessed even before they have to come for an appointment. A committee reviews the family history to determine if someone is at high risk and needs to see a genetic counselor or enter the high risk program.

Women considered to be at high risk either because of a strong family history or an abnormal, but non-cancerous biopsy have more options today in terms of prevention, such as taking tamoxifen at a regular or low dose, as well as early detection with increased or early screening with an annual breast MRI, in addition to mammography depending on what is age-appropriate.

I urge women to know their family history for all cancers, to discuss it with their health care provider and to keep up with their provider for breast and other care. We now live in an era where many decisions should fall under the category of “shared decision making” where the patient and provider work together to develop a plan that is acceptable to the patient and considered safe by the provider.

Certainly, as a breast cancer surgeon, I would rather find a cancer early so that I can minimize the treatment and maximize my patient’s quality of life.

Dr. Holly Mason is Section Chief, Breast Surgery Division of Surgical Oncology, Baystate Medical Center, Baystate Regional Cancer Program. She is one of several Baystate professionals who address issues related to cancer in this space on a rotating basis each month.