The Call-Back

If you're a woman over 40, you already know you should be getting regular mammograms to screen for breast cancer. For most of us this is just routine preventive health care—and we'll soon receive an all-clear from the radiologist. But every year a small percentage of women will get the dreaded notice, through a phone call or letter, that the scan has turned up something "suspicious." That's what happened to Barbara a few months ago. She had been getting mammograms for years with no unusual results. But, as recommended by breast cancer experts, she has always gone to the same imaging center so that her new scans can be compared to previous ones. And that's how radiologists spotted a potential problem.

American women are luckier than most because annual mammograms are an accepted tool for cancer prevention in this country. As a result, millions of women like us get regular screenings (every year or two over age 40 and annually after 50), most of which are covered by health insurance. But with so many women getting screened, the number of callbacks is also significant. No one knows exactly how many women have to return to the imaging center because of something troubling on their scans, but Robert A. Smith, director of cancer screening at the national office of the American Cancer Society, estimates that the rate in this country is about twice as high as in the United Kingdom and Europe. (Smith says that may be because some national health policies limit the number of women that radiologists—the doctors who read the mammograms—can call back. "In the United States there are no such constraints," Smith says.)

Barbara received a letter urging her to make an appointment with the imaging center. The language in these callbacks is purposefully vague to keep patients calm. In fact, a suspicious result can be everything from a shadow on the film to completely benign breast disease to a full-fledged malignancy. Barbara knows this as well as anyone. But we'll be honest: even though we are veteran medical reporters, we get just as scared as anyone else when illness looms. When Barbara first read the letter she immediately assumed the worst: that she had cancer. The imaging center was reassuring; the results, they told Barbara in a phone call, showed areas of what were described as "microcalcifications" that hadn't appeared on her mammogram a year earlier. Although these are most likely benign, they are nonetheless a cause for concern, says Dr. Larissa Korde, staff clinician in the clinical genetics branch at the National Cancer Institute, because there are often small calcium deposits in cancers, particularly in the noninvasive ductal carcinoma in situ or DCIS. "When radiologists see certain patterns in calcifications on a mammogram, they will often call a patient back," Korde says. That's especially likely if the calcifications are new since the previous mammogram, as in Barbara's case.

The first step for Barbara was a needle biopsy to take a sample of the troubling tissue. Without actual tissue to examine, doctors can't really tell what's going on. Again, Barbara was extremely nervous when she went in for this procedure, which took about an hour. It turned out to be far less uncomfortable than a mammogram. She was given local anesthesia and the pain was minimal. There wasn't even much of a mark where the needle had gone in. A week later, when she called in to get the results, the bandage was long gone. Barbara hoped this would be the end of it—that the results would show completely normal tissue. Instead, the diagnosis was atypical ductal hyperplasia (ADH), which means that cells lining the milk ducts in her breast were growing in an abnormal way. Atypical cells can also grow in a lobule, the part of the breast that produces milk. That's called atypical lobular hyperplasia (ALH). Although these two conditions may sound alarming, neither is cancer. They are what doctors call a "marker" of risk: studies have shown that women diagnosed with ADH are more likely to someday have breast cancer than women who don't have these abnormal cells. ADH also doesn't mean that the cancer would evolve at the particular place where these cells are found, says Korde. Malignant lesions could be anywhere in the breast.

Without mammograms, you probably would never know that you have microcalcifications, ADH or ALH. You can't really feel these areas if you or your doctor examine your breasts. In fact, many of us are probably walking around right now with these conditions, and they may well have no effect on our life expectancies. However, now that doctors know that ADH is a marker of increased risk, they can give women choices about what to do next. There is no single answer for all women. Since the risk of breast cancer increases with age, Smith says the recommendation would be very different for a woman in her 30s than for a woman in her 60s. A younger woman would probably be advised to start getting regular mammograms even though that screening usually starts at age 40. An older woman, already at greater risk because of her age, would get careful attention, perhaps including an ultrasound of that part of the breast or an MRI. Doctors would be even more concerned about women with additional risk factors—such as a personal or family history of breast cancer, late start of menstruation or late menopause, or a first pregnancy past age 30. "When the risk factors start stacking up, then the index of suspicion would go up as well," says Smith.

Barbara's mother had breast cancer, which, along with the ADH, increases the chances that she will someday get the disease herself. Barbara could have waited six months for another mammogram, but she decided to seek a consultation with a breast surgeon. The surgeon recommended that she get another biopsy to remove all the suspicious tissue and make sure there were no malignant cells lurking anywhere nearby. She did, and the results finally gave her the all clear she had been hoping for. However, she will now get mammograms more often, probably every six months, and will be followed by an oncologist. She is also discussing with her doctor the possibility of taking a medication called tamoxifen, which has been shown to cut the chances of breast cancer in women with ADH.